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Declaration Under UCCJA Form. This is a Illinois form and can be use in Lake Local County.
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Tags: Declaration Under UCCJA, 171-145, Illinois Local County, Lake
IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
)
)
)
Petitioner
)
)
)
)
Respondent )
and
Case Number:
Declaration Under Uniform Child Custody
Jurisdiction Enforcement Act (UCCJEA)
I,
, certify that the following statements are true:
(Your full name)
1.
and I are the parents of:
(Other parent’s full name)
date of birth:
(Child’s full name)
date of birth:
(Child’s full name)
date of birth:
(Child’s full name)
date of birth:
(Child’s full name)
date of birth:
(Child’s full name)
(Child’s full name)
date of birth:
(Attach additional pages as needed)
(mmddyyyy)
(mmddyyyy)
(mmddyyyy)
(mmddyyyy)
(mmddyyyy)
(mmddyyyy)
2. The child(ren) have lived at the following addresses in the past five years:
(mmyyyy)
(mmyyyy)
(mmyyyy)
(mmyyyy)
(mmyyyy)
(mmyyyy)
to
to
to
to
to
to
(mmyyyy)
Address
(With whom?)
(mmyyyy)
Address
(With whom?)
(mmyyyy)
Address
(With whom?)
(mmyyyy)
Address
(With whom?)
(mmyyyy)
Address
(With whom?)
(mmyyyy)
Address
(Attach additional pages as needed)
(With whom?)
3. If the child(ren) has/have lived with someone other than you at any time during the last 5 years, state
that person's name and current address(es):
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171-145 (R 12-04)
4. The child(ren) now live(s) with:
me
the other parent
both of us
other:
(Describe the child(ren)’s living situation)
.
Check the following statements that are true:
a. The child(ren) over the age of 6 months have lived in Illinois for at least the last 6 months.
5.
b. The child(ren) under the age of 6 months have lived in Illinois since birth.
6.
a. On information and belief, there are no other legal proceedings or court orders involving the
custody of, or visitation with my child(ren), and I have not participated in any other case(s)
involving custody of, or visitation with my child(ren) in this, or any other state OR
b. On information and belief, the only legal proceedings, court orders, or cases that I have
participated in involving the custody of, or visitation with my child(ren), in this, or any other
state, are those listed below:
Case Name
County/State
Date of last court order
Case Name
County/State
Date of last court order
Case Name
County/State
Date of last court order
7. Other than the parties to this case, no other person claims to have rights of custody and/or visitation
.
with the child(ren) except:
8. I understand that I have a continuing duty to inform the court of any proceeding in this or any other
state, that could affect the current proceedings.
Certification
Under penalties provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the
undersigned certifies that the statements set forth in this instrument are true and correct, except as to
matter therein stated to be on information and belief and as to such matters the undersigned certifies as
aforesaid that s/he verily believes the same to be true.
Date: ___________________
______________________________________
Signature
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171-145 (R 12-04)
