Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) (Rev. 12/21/04) CCDR 0502 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION IN RE THE MARRIAGE OF: } GEN. NO. ____________________________ ____________________________________________________ PETITIONER ____________________________________________________ RESPONDENT DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) 1. Party’s Name:__________________________________ 2. Number of minor children subject to this proceeding: _______________ Attorney’s Name: ______________________________ Additional list attached. (Provide requested information for additional children on an attachment) Insert the information requested below. The residence information must be given for the last five years. Child One Child Two Child Three ____________________________________________________________________________________________________________________________ Child’s Name and Sex _______________________________________________________________________________________________________________________ Date of Birth _______________________________________________________________________________________________________________________ Place of Birth _______________________________________________________________________________________________________________________ Child’s Current Address and Length of Residence _______________________________________________________________________________________________________________________ Name, Present Address and Relationship to Child of person that lived at current address _______________________________________________________________________________________________________________________ Child’s Previous Address and Dates of Residence _______________________________________________________________________________________________________________________ Name, Present Address and Relationship to Child of person that lived at 1st previous address _______________________________________________________________________________________________________________________ Child’s Previous Address and Dates of Residence _______________________________________________________________________________________________________________________ Name, Present Address and Relationship to Child of person that lived at 2nd previous address DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 12/21/04) CCDR 00502 B 3. Have you participated as a party, witness, or in some other capacity in another litigation or custody proceeding, either in Illinois or elsewhere, concerning custody of a child subject to the proceeding? Yes No 4. Do you have information about a custody proceeding pending in an Illinois court or any other court concerning a child subject to this proceedings, other than that stated in item 3? Yes No 5. Do you know of any person who is not a party to this proceeding who has physical custody, or claims to have custody of, or visitation rights with, any child subject to this proceeding? Yes No If the declaration as to any of the above items is in the affirmative the declarant shall give additional information under oath as required by the Court. Each party has a continuing duty to inform the Court of any custody proceeding concerning the child in this or any other state of which s/he obtained information during this proceeding. I declare under penalty of perjury under the laws of the State of Illinois that the foregoing is true and correct. ____________________________________________ ____________________________________________ (Type or print name) (Signature of Declarant) 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