Print Form Clear Form Rule 13.3.3 Custody Disclosure Statement (Rev. 12/08/14) CCDR 0044 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION In Re the: q Marriage q Civil Union q Custody q Support of: ______________________________________________________ Petitioner and No. ___________________________________ ______________________________________________________ Respondent RULE 13.3.3 CUSTODY DISCLOSURE STATEMENT INSTRUCTIONS A. Upon determination by the court that custody is a contested issue, the court may order that this custody disclosure statement be completed by each party to the contested custody issue. B. The completed custody disclosure statements must be signed, verified, and delivered to opposing counsel, or if no counsel, to the opposing party, but not filed with the court. A certificate of service shall be completed and filed with the court. C. This custody disclosure statement may be reviewed by the court for pretrial purposes, but shall not become a part of the file. DISCLOSURE 1. State your name, current address and date of birth. 2. State the name(s) of your child(ren) and date(s) of birth. 3. Are you married to/have a civil union with the other parent? 4. Are there parentage issues? If so, explain. 5. Is there a current Order related to custody or visitation? If so, summarize its terms and provide date of Order. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 5 Rule 13.3.3 Custody Disclosure Statement (Rev. 12/08/14) CCDR 0044 B 6. Are there other actions pending related to custody or visitation? Provide case number and explain the proceedings. 7. If you are seeking custody of your child(ren): a. Would you be able to devote your full time to the child(ren)'s care and upbringing? b. If not, who would be able to devote full time care when you are not available? Please name each person/ institution that you will rely on to care for the child(ren). 8. Are there any special needs or medical problems related to the child(ren)? If so, identify the child and your understanding of the problem. 9. Describe your current residence, i.e., number of bedrooms, bathrooms, etc. 10. Do you have any plans to move? If so, when and where? 11. Does anyone live with you? If so, name each person with whom you live; how long you have known him/her them; describe your relationship with him/her/them; and provide a description for each one. 12. If you are presently employed, state your work days and hours and whether you are required to work overtime. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 5 Rule 13.3.3 Custody Disclosure Statement (Rev. 12/13/13) CCDR 0044 C 13. For the 24 months preceding your separation, who primarily performed the following duties for the child(ren)? If both, what percentage of each did you perform? Petitioner Prepared meals. Took the child(ren) to the doctor. Administered medication. Prepared child(ren) in the morning. Put child(ren) to bed. Attended parent/teacher conferences. Arranged for child care. Enrolled child(ren) in extracurricular activities. Transported child(ren) to activities. Attended child(ren)'s activities and events. Assisted with homework. If applicable, took the child(ren) to place of worship. 14. Disclose with particularity the action, inaction or conduct, that you intend to place into evidence at the time of trial or hearing supporting your petition or claim. The description should include dates, places and persons present. Respondent 15. Disclose the name of each person that has pertinent information pertaining to custody/visitation of the children. In addition, disclose which, if any, such persons you will call as witnesses. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 3 of 5 Rule 13.3.3 Custody Disclosure Statement (Rev. 12/13/13) CCDR 0044 D 16. As to each agency, school or other entity, whose records or documents you intend to offer into evidence, reveal the name of the entity, the name of the records or documents, and attach same to this disclosure. 17. If writings, documents, electronic recordings, or photographs are intended to be used in evidence at the time of trial or hearing, disclose the name, address and telephone number of the person or persons who possess those materials. 18. Disclose all documents, writings, electronic recordings, photographs and other physical evidence containing the words, writings or admissions of the other parent that you intend to use during the course of the trial. 19. If you are not granted sole physical custody, state with specificity the visitation time that would be appropriate, including overnights, holidays and school vacations. 20. If you are granted sole physical custody, state with specificity the visitation time that would be appropriate for the other parent. 21. State whether you are aware of disagreement(s) with the other parent concerning the child(ren)'s education, religious upbringing, health care needs, discipline, other (identify) and/or extracurricular activities and, if so, complete the following: Type of Disagreement Education. Religious upbringing. Healthcare. Extracurricular activities. Discipline. 22. Is joint custody a possibility for you? If new information comes to your attention, you have an obligation to update your answer to keep the disclosure statement current. Explain Differences DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 4 of 5 Rule 13.3.3 Custody Disclosure Statement (Rev. 12/13/13) CCDR 0044 E The disclosure herein will noT be a subsTiTuTe for complying wiTh rules of evidence aT The Time of Trial or hearing. however, The disclosures may be used To limiT The scope and naTure. ____________________________________________ Signature of Party The foregoing custody Disclosure Statement has been carefully read by the undersigned who states under oath, under penalties as provided by law pursuant to 735 ILCS 5/1-109, that s/he has knowledge of the matters stated and that the statements set forth in this Custody Disclosure Form are true and correct, except as to matters specifically stated to be on information and belief, and as to such matters the undersigned certifies as aforesaid that s/he believes same to be true. _____________________________________________ Signature of Party q Petitioner q Respondent ____________________________________________ Type or Print Name Subscribed and sworn to before me this day o