Print Form Clear Form 2800 - Affidavit 3558 - Disclosure Statement Filed 3128 - Answer to Asset/Financial Disclosure Statement Filed (Rev. 12/15/14) CCDR 0604 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION In Re the: Marriage Civil Union Custody Support Parentage ______________________________________________________ Petitioner and ______________________________________________________ Respondent No. ___________________________________ Calendar: ______________________________ DISCLOSURE STATEMENT (Pursuant to Rule 13.3.1) STATE OF _______________________ COUNTY OF ____________________ ss: Petitioner/Respondent, _________________________________________, being duly sworn, deposes and says that the following is an accurate statement as of _____________________________ , ________, of my net worth (assets of whatsoever kind and nature and wherever situation minus liabilities), statement of income from all sources, statement of monthly living expenses, statement of health insurance coverage, and statement of assets transferred of whatsoever kind and nature and wherever situated: Name: _____________________________________________ Address: ____________________________________________ ___________________________________________________ Date of Marriage/Civil Union: ___________________________ Parties reside in the same household: Full Name(s) ___________________________________ ___________________________________ ___________________________________ Yes No Civil Union or DOB __________ __________ __________ Parentage: Residing with ____________________________________________ ____________________________________________ ____________________________________________ Age __________ __________ __________ Minor and/or Dependent Children of this Marriage Telephone No.:_________________________________________ Date of Birth: __________________________________________ Date of Dissolution of Marriage/Civil Union: _________________ (if applicable) Current Employer: ____________________________________ Self Employment: _____________________________________ Other Employment: ___________________________________ Check if unemployed Number of Paychecks per year 12 24 26 52 Number of exemptions claimed: _____________ Number of Dependents claimed: _____________ Address: ______________________________________________ Address: ______________________________________________ Address: ______________________________________________ Gross income from all sources last year: ____________________________________________________________________________ Gross income from all sources this year through: _____________________________________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 10 2800 - Affidavit 3558 - Disclosure Statement Filed 3128 - Answer to Asset/Financial Disclosure Statement Filed STATEMENT OF INCOME Gross Monthly Income (Rev. 12/15/14) CCDR 0604 B Case No. ____________________________ as of _______________________________ $ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ $ ___________________ Salary/wages/base pay _______________________________________________________________ Overtime/commission _______________________________________________________________ Bonus ___________________________________________________________________________ Draw ____________________________________________________________________________ Pension and retirement benefits________________________________________________________ Annuity__________________________________________________________________________ Interest income ____________________________________________________________________ Dividend income __________________________________________________________________ Trust income ______________________________________________________________________ Social Security _____________________________________________________________________ Unemployment benefits _____________________________________________________________ Disability payment _________________________________________________________________ Worker's compensation ______________________________________________________________ Public Aid/Food stamps _____________________________________________________________ Investment income _________________________________________________________________ Rental income _____________________________________________________________________ Business income ___________________________________________________________________ Partnership income _________________________________________________________________ Royalty income ____________________________________________________________________ Fellowship/stipends _________________________________________________________________ Other income (specify) ______________________________________________________________ Total Gross Monthly Income Required Monthly Deductions Federal Tax (based on ___________ exemptions) __________________________________________ $ ___________________ State Tax (based on __________ exemptions)_____________________________________________ FICA (or Social Security equivalent) ____________________________________________________ Medicare Tax ______________________________________________________________________ Mandatory retirement contributions required by law or as a condition of employment _______________________________________________________ Union Dues (Name of Union:_______________________________ ) _________________________ Health/Hospitalization Premiums ______________________________________________________ Prior obligations(s) of support actually paid pursuant to Court order ___________________________ Expenditures for repayment of debts that represent reasonable and necessary expenses for the production of income (identify and itemize)__________________________ Medical expenditures necessary to preserve life or health _____________________________________ Reasonable expenditures for the benefit of the child and the other parent exclusive of gifts (for non-custodial parent