(Rev. 4/19/01) CCSD 0053 IDPA USE ONLY CIRCUIT COURT OF COOK COUNTY APPLICATION FOR CHILD SUPPORT SERVICES WITH THE IV-D AGENCY CAT. CO/DIST. GRP. BASIC ____________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME TELEPHONE NUMBER _____________________________________________________________________________________________________ STREET ADDRESS APT. NO. SOCIAL SECURITY NUMBER _________ SEX CITY STATE ____/____/____ DATE OF BIRTH ZIP __________________ RACE I HEREBY APPLY TO THE CLERK OF THE CIRCUIT COURT/STATE'S ATTORNEY OF COOK COUNTY FOR THE FOLLOWING SERVICES: ____ CHILD SUPPORT SERVICES ( Includes Absent Parent Location, Support Enforcement and Collection, if Necessary.) NO FEE REQUIRED ____ PATERNITY DETERMINATION (Dose not include Support Enforcement and/or Collection Services.) NO FEE REQUIRED. ____ LOCATION SERVICE ONLY (Does not include Support Enforcement and/or Collection Services.) NO FEE REQUIRED. I UNDERSTAND THAT: 1. The service requested DOES NOT include the obtaining of a divorce, enforcement of property settlements, or determination or enforcement of visitation and custody issues. I must retain a private attorney for these matters. 2. I must cooperate fully in all efforts to furnish the service requested. This includes supplying copies of any prior court orders, providing location leads, and giving necessary testimony at court hearings. 3. There is no guarantee that support payments will be obtained or the services rendered will be successful. 4. Support efforts may be discontinued if further action is inadvisable or legally impossible. 5. I must report any changes of my address promptly to the Clerk of the Circuit Court of Cook County, Room 200, 28 North Clark St., Chicago, Illinois 60602. I AGREE THAT: All support payments will be made payable to the Clerk of the Circuit court and will be forwarded to me. Indicate below each person currently dependent upon you for support (including yourself) and his/her gross income per month. NAME FIRST LAST RELATIONSHIP SEX D. O. B. Soc. Sec. Number GROSS MONTHLY INCOME Amount Source _____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________ I HEREBY AFFIRM THAT I AM THE CUSTODIAN OF THE CHILD(REN) FOR WHOM I SEEK SUPPORT SERVICES AND THAT I AM A RESIDENT OF THE STATE OF ILLINOIS. FURTHERMORE, I AUTHORIZE THE IV-D AGENCY OR ITS DESIGNEES TO EXPLORE, PURSUE, OR UTILIZE ALL SOURCES OF INFORMATION LEGALLY AVAILABLE TO IT IN SUPPORT OF ITS INVESTIGATIONS AND TO CHOOSE THE APPROPRIATE COURSE OF LEGAL ACTION. TO THE BEST OF MY KNOWLEDGE, THE INFORMATION I HAVE SUPPLIED IS TRUE, CORRECT AND COMPLETE. APPLICANT'S SIGNATURE _________________________________________ DATE ________________________________ INTERVIEWER'S SIGNATURE ______________________________________ DATE _________________________________ 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