Case Number(s)Arresting Agency(ies)Charge(s)Date(s) of ArrestSID/IR/DCN/CBDisposition Prepared by: Cook County Attorney Code: Address: City/State/Zip: Telephone: Primary Email: Secondary Email: Tertiary Email: Defendant/PetitionerDated: Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, 735 ILCS 5/1-109, the undersigned certi002 es that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certi002 es as aforesaid that s/he verily believes the same to be true. Received this day of (State220s Attorney/Prosecutor/ISP/Arresting Agency/Chief Local Government Legal O003 ce)