Clerk of the Circuit Court of Cook County Record Request Form Child Support Division Correspondence Room 200 28 North Clark Street Chicago, Illinois 60602 (312) 345-4045 Your request is subject to approval under the applicable provisions of the constitution and statutes of the state of Illinois, the Illinois Supreme Court Rules, and the local policy and procedures. PLEASE DO NOT SEND ANY PREPAYMENT ! After we receive your request you will be notified of the cost. All Government agencies must submit their request on Government Letterhead. Requestor Information Name of Requestor: ______________________________________________________________ Address: ______________________________________________________________ City: ______________________ State:____________ Zip Code: _____________ Day or Work Phone: ______________________________________________________________ Case Number: ______________________________________________________________ Petitioner Name(s): ______________________________________________________________ Name used when case was filed Respondent Name(s): ______________________________________________________________ Name used when case was filed Petitioner SS# ___________-_______-___________
Check here for list of paymentRespondent SS# ___________-_______-___________ Records Requested: ___________________________________________________________________ ______________________________________________________________________________________________ Please complete this form as fully as possible and mail to the address above.The requestor will be responsible for statutory fees (see Section 27.2a of the Clerks Act (705 ILCS 105/27.2a) which can include but are not limitedto, the following: search fees; copying charges; certification charges (if necessary); and postage. Prior to processsing the request, the requestor willbe notified of the charges and expected to remit advance payment. PLEASE DO NOT SEND ANY PREPAYMENT.______________________________________________________________________________________ Signature of requestor Date Fee Schedule (See 705 ILCS 105/27.2a) Record Searches Certified Copies Copies$9.00 per year and $9.00 per certified document First page at $2.00division or district Next 19 pages at $.50 Remaining pages at $.25 This request may take 4 to 6 weeks for processing. (11/08/04) CCSD 0004