Print Form 3400 - Pre-Trial Memorandum Filed Uniform Settlement Pretrial Conference Memorandum Clear Form (Rev. 7/30/12) CCDR 0043 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION IN RE THE MARRIAGE/CIVIL UNION ____________________________________________________ No. __________________________________ PETITIONER AND ____________________________________________________ Calendar: ____________________________ RESPONDENT UNIFORM SETTLEMENT PRETRIAL CONFERENCE MEMORANDUM PREPARED BY: ______________________________________ (Petitioner or Respondent) (Add Addendum if more space is required.) Date of Civil Union/Marriage: _________________________ Date of Separation: ______________________________ Petitioner’s Age D/O/B: ______________________________ Respondent’s Age D/O/B: _______________________ Petitioner’s Occupation: ______________________________ Respondent’s Occupation: _____________________ Income from all sources to date (as calculated for child support purposes): Last year’s gross: Petitioner: ________________ Respondent: ________________ Last year’s net: Petitioner: ________________ Respondent: ________________ Assets: (from Schedules A & C) Civil Union/ P Non-Civil Union/ R Non-Civil Union/ Marital Value1 Non-MaritalValue Non-Marital Value (1) Equity in real estate (2) Cash/cash equivalents $ ____________ $ ____________ (3) Investment accounts/securities (4) Business interests (including Partnerships, Corporations, LLCs) (5) Stock Options/ESOs (other employment benefits) $ ____________ (6) Cash value of life insurance (7) Equity in motor vehicles, RVs, boats, aircraft $ ____________ $ ____________ (8) Personal property (9) IRA accounts, deferred compensation, annuities, 401(k), profit-sharing $ ____________ $ ____________ (10) Pension plans (11) Other property TOTAL ASSETS: ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ $ ____________ $ ____________ 0.00 $ ____________ ____________ ____________ ____________ 0.00 ____________ ____________ ____________ ____________ 0.00 ____________ LESS LIABILITIES (from Schedules B & C): (excluding liens on real estate, motor vehicles, RVs, boats, aircraft) $ ____________ Assets Less Liabilities: $ ____________ Reimbursement Claim (from Schedule D): $ ____________ Dissipation Claim(s) (from Schedule E): $ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ $ ____________ $ ____________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS 1 Value listed should reflect most current value of asset (Page 1 of 10) Child(ren)’s Information: Name(s) ___________________________________ School Child Attending: _________________________________ Birthdate(s) ________________________________School Expenses/Tuition: ___________________________________ Health/Education Issues:______________________________________________________________________________ Name(s) ___________________________________ School Child Attending: _________________________________ Birthdate(s) ________________________________School Expenses/Tuition: ___________________________________ Health/Education Issues:______________________________________________________________________________ Name(s) ___________________________________ School Child Attending: _________________________________ Birthdate(s) ________________________________School Expenses/Tuition: ___________________________________ Health/Education Issues:______________________________________________________________________________ Name(s) ___________________________________ School Child Attending: _________________________________ Birthdate(s) ________________________________School Expenses/Tuition: ___________________________________ Health/Education Issues:______________________________________________________________________________ Other Issues Pertaining to Parties; Petitioner Health: ________________________________________ _______________________________________________ _______________________________________________ Respondent ______________________________________________ _______________________________________________ _______________________________________________ Current Income Disputes and Basis: _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Educational History (Highest degree attained) _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ GROUNDS: (Specify party alleging grounds); ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ *See Schedule H if there are Custody or Visitation Issues (Rev. 7/30/12) CCDR 0043 (Page 2 of 10) SCHEDULE A CIVIL UNION/MARITAL ASSETS (Add Addendum if more space is required.) 1. Real Estate Address Title in P/R Date Value Value Liens Net Equity ___________________________ ___________________________ ___________________________ ___________________________ _____________ _____________ _____________ _____________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ 0.00 Total Equity in Real Estate: ____________________________________________________________________________ 2. Cash/Cash Equivalents If Institutions/Account No. (Use last 3 digits of account no.) Title Date Valued __________________________ __________________________ __________________________ __________________________ ________________________ ________________________ ________________________ ________________________ ______________ ______________ ______________ ______________ Value ______________ ______________ ______________ ______________ 0.00 Total Value of Cash/Cash Equivalents: ____________________________________________________ 3. Investment Accounts/Stock/BondsMutual Funds/Secured/Unsecured Receivables/Other Institutions/Account No. (Use last 3 digits of account no.) Title in P/R Date Valued Value __________________________ __________________________ __________________________ __________________________ _______________________ _______________________ _______________________ _______________________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ Total Value of Investment Accounts/Stock/Bonds/Mutual Funds/Secured/Unsecured/Receivables/Other: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ (Rev. 7/30/12) CCDR 0043 (Page 3 of 10) 4. Business Interests (including Partnerships, Corporations and LLCs) Name of Business Form of Ownership % of P/R Ownership Date Valued Value ___________________________ ___________________________ ___________________________ ___________________________ ___________________ ___________________ ___________________ ___________________ ____________ ____________ ____________ ____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ 5. Stock Options/ESOPS/Other Employee Benefits Name of plan P/R Date Valued Value _________________________________ _________________________________ _________________________________ _________________________________ ___________ ___________ ___________ ___________ ____________ ____________ ____________ ____________ _____________ _____________ _____________ _____________ 6. Life and Disability Insurance Policies Name of Company Policy Number Name of Insured Description of Benefit 1. 2. 3. 4. _______________ _______________ _______________ _______________ _____________________ _____________________ _____________________ _____________________ ______________________ ______________________ ______________________ ______________________ Owner Cash Value Date Valued 1. 2. 3. 4. _______________________________ _______________________________ _______________________________ _______________________________ _______________ _______________ _______________ _______________ ____________ ____________ ____________ ____________ 7. Motor Vehicles/RVs/Boats/Aircraft _______________________________ _______________________________ _______________________________ _______________________________ Year/Make/Model Title in P/R Date Valued Value Liens Net Equity ________________________ ________________________ ________________________ ________________________ ____________ ____________ ____________ ____________ __________ __________ __________ __________ _________ _________ _________ _________ __________ __________ __________ __________ __________ __________ __________ __________ (Rev. 7/30/12) CCDR 0043 (Page 4 of 10) 8. Personal Property (including coins, stamps, art, antiques, etc.) Description Value Date Valued Title in P/R _________________________________ _________________________________ _________________________________ _________________________________ ___________ ___________ ___________ ___________ ____________ ____________ ____________ ____________ ______________________________ ______________________________ ______________________________ ______________________________ 9. IRA Accounts/Deferred Compensation/Annuities/401(k) Profit-Sharing Institutions/Account No. (Use last 3 digits of account no.) P/R Date Valued Value or Benefit 1. 2. 3. 4. ______________ ______________ ______________ ______________ ____________ ____________ ____________ ____________ ________________________ ________________________ ________________________ ________________________ _______________________ _______________________ _______________________ _______________________ Type of plan 1. 2. 3. 4. ___________________________ ___________________________ ___________________________ ___________________________ 10. Pension Plans Name of Plan P/R Date Valued Value or Benefit _____________________________ _____________________________ _____________________________ _____________________________ ______________ ______________ ______________ ______________ ____________ ____________ ____________ ____________ ________________________ ________________________ ________________________ ________________________ 11. All Other Property Not Elsewhere Provided (including choses in action): Description Value Date Valued Value or Benefit _____________________________ _____________________________ _____________________________ ______________ ______________ ______________ ____________ ____________ ____________ ________________________ ________________________ ________________________ _____________________________ ______________ ____________ ________________________ (Rev. 7/30/12) CCDR 0043 (Page 5 of 10) SCHEDULE B DEBTS/LIABILITIES (Exclude liens on Real Estate, Autos, RVs, Boats, Aircraft) Creditor Name/Last 4 Digits of any Acct. No. Debtor/Name(s) on Acct. if Applicable Total Balance Owed Monthly Payment _________________ _________________ _________________ _________________ ________________ ________________ ________________ ________________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ SCHEDULE C NON-CIVIL UNION/NON-MARITAL PROPERTY, DEBT AND EQUITY (for Real Estate, Autos, RVs, Boats and Aircraft) Provide same details as required of assets in Schedule A. Petitioner Non-Civil Union/Non-Marital Asset Title Value Non-Marital/ Non-Civil Union Debt Date of Value 1. _______________ ______________________ ______________________ ______________________ ______________________ ____________ ____________ ____________ ____________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ 2. _______________ 3. _______________ 4. _______________ Basis of Non-Civil Union/Non-Marital Claim (for above): 1. _____________________________________________________ 2. _____________________________________________________ 3. _____________________________________________________ Respondent Non-Civil Union/Non-Marital Asset Title Value Non-Marital/ Non-Civil Union Debt Date of Value 1. _______________ ______________________ ______________________ ______________________ ______________________ ____________ ____________ ____________ ____________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ 2. _______________ 3. _______________ 4. _______________ Basis of Non-Civil Union/Non-Marital Claim (for above): 1. _____________________________________________________ 2. _____________________________________________________ 3. _____________________________________________________ (Rev. 7/30/12) CCDR 0043 (Page 6 of 10) SCHEDULE D CLAIMS FOR REIMBURSEMENT FROM ONE ESTATE TO ANOTHER Amount and Estate from which Reimbursement Claimed and to which Estate it is Due ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Basis for Claims for Reimbursement ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ SCHEDULE E ALLEGED DISSIPATION State the amount/basis/time frame of each dissipation: ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ SCHEDULE F STATEMENT OF LITIGATION EXPENSES PAID AND OWED Petitioner’s litigation expenses paid: $ ____________; Owed _____________ As of Date: _____ /_____ /_____ Respondent’s litigation expenses paid: $ ____________; Owed _____________ As of Date: _____ /_____ /_____ Child Representative’s litigation expenses paid: $ ____________; Owed _____________ As of Date: _____ /_____ /_____ SCHEDULE G MEDICAL INSURANCE Describe current insurance available and any claims with regards to insurance ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Name of party to carry medical insurance ____________________________________________________ Outstanding medical obligations and responsibilities ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ (Rev. 7/30/12) CCDR 0043 (Page 7 of 10) SCHEDULE H CUSTODY Current order or status in effect relating to custody, visitation and child support (Describe): ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 1.) If no custody disclosure statement has been served please state the following: a. The basis for seeking custody: ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ b. Child Support Proposal: (If deviation from child support guidelines is requested, state reasons) ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ c. Are there any other court proceedings having a bearing on custody, visitation and support (Name of case, type of action and last court order) ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ d. A Custody Disclosure Form HAS ‰ HAS NOT ‰ been served. *If a Custody Disclosure Form HAS been served please attach a copy. (Rev. 7/30/12) CCDR 0043 (Page 8 of 10) SETTLEMENT PROPOSAL 1.) Maintenance Proposal (Amount, Duration and Reason(s) for Duration or Denial): ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 2.) Allocation of Civil Union/Marital Assets: ASSET NET VALUE PETITIONER RESPONDENT ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ Adjustment for dissipation or reimbursement: _____________ __________________ __________________ TOTAL: 0.00 _____________ 0.00 __________________ 0.00 __________________ 3.) Assignment of Non-Civil Union/Non-Marital Property: ASSET NET VALUE PETITIONER RESPONDENT ________________________________________ ________________________________________ ________________________________________ ________________________________________ _____________ _____________ _____________ _____________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ TOTAL: 0.00 _____________ 0.00 __________________ 0.00 __________________ CREDITOR AMOUNT PETITIONER RESPONDENT ________________________________________ ________________________________________ ________________________________________ ________________________________________ _____________ _____________ _____________ _____________ 0.00 _____________ __________________ __________________ __________________ __________________ 0.00 __________________ __________________ __________________ __________________ __________________ 0.00 __________________ 4.) Assignment of Civil Union/Marital Debt: TOTAL: (Rev. 7/30/12) CCDR 0043 (Page 9 of 10) 5.) Assignment of Non-Civil Union/Non-Marital Debt: CREDITOR AMOUNT PETITIONER RESPONDENT ________________________________________ ________________________________________ ________________________________________ ________________________________________ _____________ _____________ _____________ _____________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ TOTAL: 0.00 _____________ 0.00 __________________ 0.00 __________________ 6.) School Expenses: LIST EXPENSES PARTY OBLIGATED TO PAY _______________________________________ _______________________________________ _______________________________________ ____________________________ ____________________________ ____________________________ 7.) Attorneys, Other Litigation Fees and Costs, Proposal ATTORNEY FEES OTHER LITIGATION FEES AND COSTS PROPOSAL ______________ ______________ ______________ ______________ _________________________ _________________________ _________________________ _________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Submitted by: _______________________________________ Petitioner/Respondent Date Submitted: ______________________, __________ Signed: _______________________________________ Petitioner/Respondent Atty. No.: ______________ Name: __________________________________________ Atty for: ________________________________________ Address: ________________________________________ City/State/Zip: _____________________________________ Telephone: _______________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 7/30/12) CCDR 0043 (Page 10 of 10)