2331 (Rev. 07/05) PETITION TO ESTABLISH A PARENT-CHILD RELATIONSHIP STATE OF ILLINOIS UNITED STATES OF AMERICA COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT CASE NUMBER IN RE: Establishment of a ParentChild Relationship by Consent A MINOR File Stamp Here PETITION TO ESTABLISH A PARENT-CHILD RELATIONSHIP BY CONSENT We, the undersigned, hereby petition the Court for entry of an Order establishing a parent-child relationship brought pursuant to Paragraph 6, Illinois Parentage Act 1984, as amended 750 ILCS 45/6 et. seq., and in support of said petition, petitioners being first duly sworn upon oath state: 1. The child on was born in (date). born on 2. The child's natural mother is and is currently residing in in Her social security number is . She was not married at the time of conception of this child, nor has she been married since that time. born on 3. The child's natural father is and is currently residing at in . WHEREFORE THE PETITIONERS PRAY: 1. That the Court determine 2. That the following issues be reserved: Expenses of Child Birth Child Support Medical Support to be the natural father of the minor child. Health Insurance Coverage Reimbursement of Public Assistance Retroactive Support Visitation by non custodial parent Educational expense of the minor child Child Care expense 3. That the natural mother be given temporary care and custody of the minor child. I understand that by my signature on this petition and the accompanying proposed Court Order that I am submitting to the jurisdiction of the Court as if I had been served with summons. I understand that I have a right to legal counsel, a blood test and a trial by jury and I waive those rights along with all others. I further understand that the legal relationship of the parent and child imposes duties and obligations upon the parent, including that of support. Under penalties as provided by law pursuant to 735 ILCS 5/1-109, we the undersigned hereby certify that the statements set forth in this petition are true and correct. Father Mother Legal Guardian, if Minor Legal Guardian, if Minor Signed and Sworn to me this day of Notary Public-Circuit Court Clerk , 20 Signed and Sworn to me this day of , 20 Notary Public-Circuit Court Clerk CHRIS KACHIROUBAS, CLERK OF THE 18TH JUDICIAL CIRCUIT COURT © American LegalNet, Inc. WHEATON, ILLINOIS 60189-0707 www.USCourtForms.com