Affidavit for Change of Name/Address (8/12/04) CCSD 0003 OFFICE OF THE CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS AFFIDAVIT FOR CHANGE OF NAME/ADDRESS “UNCLAIMED CHECK” Please fill out this form completely, HAVE IT NOTARIZED, then return to our office located at 28 N. Clark Street; Chicago, IL 60602. This information is needed to update our records and properly distribute your child support payments. Our office can be reached at (312) 345-4113; FAX (312) 345-4146. If you would like your payments to be directly deposited, please call (312) 345-4040. If you need TO CHANGE YOUR NAME AS IT CURRENTLY APPEARS on your child support check because: 1) you have remarried, please attach a copy of the marriage license certificate from your local city/village hall/county clerk. 2) you have resumed the use of your maiden name, please attach a copy of the court-order divorce decree authorizing this name change. We only need the first and last 2 pages. Be sure to include the page that states that you can use your maiden name. Your direct deposit will not be affected by your address being updated. THIS FORM WILL BE RETURNED IF IT IS NOT COMPLETED IN FULL AND NOTARIZED = = = = = = = = = = = = = = = = = = = = = = = = = I, _______________________________________________ on oath state that I am the party whose name appears on: (please print your name) A. Court docket number(s): ________________________ B. Please provide the name and social security number of the parent paying for support of child(ren): ______________________________________________________________________________________________________ C. Name(s) of child(ren): ____________________________________________________________________________________ ______________________________________________________________________________________________________ D. I would like to have my child support payments mailed to the following address: ______________________________________________________________________________________________________ (address) (apt #) (city) (state) (zip code) I will be moving to this address, or this address takes effect on: _____________________________, _________ Home phone no. (_______) ___________________________ Work phone no. (_______) ___________________________ Your social security no. ______________________________ Date of birth __________________________ Your child(ren)’s social security No(s). _________________________________________________________________________ ____________________________________________ ______/______/______ Signature Date signed NOTARY: Please put your seal in this space Subscribed and sworn to before me this: _______ day of ___________________, ________ My commission expires ______/______/______ Check if seal is embossed _____________________________________________ Notary Public Signature DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form