(Rev. 6/14/02) CCDR 0108 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - DOMESTIC RELATIONS DIVISION ! ! IN RE THE MARRIAGE ! CUSTODY SUPPORT OF: _______________________________________________ PETITIONER NO. AND CALENDAR: _______________________________________________ RESPONDENT FAMILY SUPPORT AFFIDAVIT This completed form must be attached to any judgment, decree or order of court which contains an initial or modification of an order for the payment of child support and/or maintenance. Both parties may use one form or they may complete separate forms. If either party is not present, both Part I and Part II must be completed by the party who is present to the best of her/his information and belief. PART I. To Be Completed by Custodial Parent Full Name ____________________________________________________ Date of Birth _________________________ Residential Address __________________________________________________________________________________ City ____________________________ County __________________ State _______________ Zip _________________ Mailing Address (if different) __________________________________________________________________________ Social Security No. ___________________ Home phone (_____) ________________ Work phone (_____)______________ Employer ____________________________________________________________________________________________ Address ____________________________________________________________________________________________ City ____________________________________ County _______________ State _______________ Zip _______________ Driver’s License No. (Illinois) _______________________ Driver’s License No. (other state) ________________________ Child(ren) covered by Order For Support: Full Name(s) Sex Date of Birth Social Security No. _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Child (ren) receiving Public Assistance? (Yes or No) ______________ If yes, give case number: _____________________________________ Title IV-D Program (Yes or No) ______________________________ If yes, give case number ______________________________________ See Reverse Side DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 6/14/02) CCDR 0108 B PART II. To Be Completed by Non-Custodial Parent Full Name ___________________________________________________ Date of Birth ____________________________ Residential Address _________________________________________________________________________________ City____________________________________ County _______________ State _______________ Zip_________________ Mailing Address (if different) _____________________________________________________________________________ Social Security No. _________________ Home telephone (_____) _______________ Work telephone (_____)_____________ Employer___________________________________________________________ Telephone (_____)___________________ Address________________________________________________________________________________________________ City____________________________________ County _______________ State _______________ Zip_________________ Occupation ____________________________________________________________________________________________ Height: ________ Weight: ________ Eyes: ________________ Complexion: _____________________________________ Race: ____________________ Birthplace (City, State) _______________________________________________________ Driver’s License No. (Illinois) _______________________ Driver’s License No. (other state) ________________________ Father's Name (last, first) _______________________________________________________________________________ Mother's Name (maiden, first) ______________________________________________________________________________ Military Service? __________________________ If yes, which Branch? _________________ Retired? _______________ *A party shall report to the Clerk of the Circuit Court of Cook County changes in information required to be disclosed pursuant to 750 ILCS 5/505.3 within five (5) business days of the change. CERTIFICATION Under penalties provided by law pursuant to 735 ILCS 5/1-109 of the Illinois Code of Civil Procedure, the undersigned certifies that he/she knows the statements set forth in this document are true and correct, except as to matters therein specifically stated to be on information and belief and as to those matters the undersigned certifies that he/she believes them to be true. ________________________________ _______________ Custodial Parent Date * * ______________________________________________________ Attorney for Custodial Parent _______________________________ Non-Custodial Parent * * _______________ Date * _________________________________________________ Attorney for Non-Custodial Parent Atty. No.: _______________ Atty. Name: ____________________________________ Atty. for: ______________________________________ Address: _____________________________________ City/State/Zip:_________________________________ Telephone: ___________________________________ 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