IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ) ) ) ) ) ) ) ) Respondent ) Petitioner vs. Gen. No. PETITION FOR DISSOLUTION OF MARRIAGE , the Petitioner, representing myself, state that: I, Name Part A. Jurisdiction (One party must be a resident of the State of Illinois for at least 90 days prior either to the filing of this Petition or to the entry of the Judgment for Dissolution of Marriage). 1. Petitioner a. I am years of age. . b. I presently reside at City/County and State c. My occupation is that of: . 2. Respondent a. The Respondent is years of age. . b. The Respondent presently resides at City/County and State c. The Respondent’s occupation is that of: . 3. Marriage ____________________________. a. The Respondent and I were married on (mmddyyyy) b. The marriage took place in and the marriage is City/County and State registered in that state and county. 4. Residency (Check all that apply): a. I have lived in Illinois since . Month/Year b. My spouse has lived in Illinois since . Month/Year 5. Other Proceedings (Check one) a. No petition for dissolution of marriage between the parties is pending in any other county or state. b. There is another petition for dissolution of marriage between the parties is pending in: City/County and State American LegalNet, Inc. www.USCourtForms.com Page 1 of 4 174-CSR200 (Rev 09/04) Part B. Children/ Related Cases 1. Children (Check all that apply): (A completed Declaration Under Uniform Child Custody Jurisdiction Enforcement Act (UCCJEA) form must be attached to this petition.) a. We have no children together. or b. That I am / am not currently pregnant. or c. That my spouse is / is not currently pregnant. (If no child(ren), skip to Part B, paragraph 4). d. The following child(ren) were born to or adopted by myself and my spouse and me during the marriage: Date of Birth (mmddyyyy) Name Currently Living With (Attach additional pages as needed) 2. It is in the best interests of the child(ren) that (check one): a. Temporary and permanent sole custody of be awarded to the Petitioner Respondent. Name of Child(ren) b. Temporary and permanent joint custody of be awarded to the parties with Petitioner Name of Child(ren) Respondent as the residential parent. 3. It is in the best interests of the child(ren) that the Court provide for visitation as follows (check one): a. Deny Restrict visitation because: . b. Grant visitation as follows: . 4. I know of the following related cases pending or closed concerning the parties or child(ren) (such as domestic violence, paternity, divorce, custody, visitation or juvenile court cases, support, etc.): County/State Case Number Kind of Case Year Filed Pending or Closed (Attach additional pages as needed) Part C. Support (Affidavit of Income and Expenses must be filed in the court at the time of any hearing on support and maintenance.) (Check all that apply) 1. a. The Respondent is is not employed. b. The Respondent is is not able to contribute to the support of our minor child(ren) and myself. American LegalNet, Inc. www.USCourtForms.com Page 2 of 4 174-CSR200 (Rev 09/04) 2. I am / am not (check one) seeking maintenance (support) for myself because: . Part D. Property (You do not have to complete Part D if you are not asking the court to make decisions about your property.) (Attach additional pages as needed) 1. My spouse and/or I have the following marital property and debts (check all that apply): Real Estate/House(s): Street Address Pension(s): Name of Company Bank account(s) and investment(s): Name of Financial Institution Motor Vehicle(s): Year, Make and Model Debts (attach list) Other: 2. I claim the following property as my non-marital property because the property was acquired prior to our marriage by gift by inheritance other: . 3. I acknowledge the following property as my spouse’s non-marital property because the property as acquired prior to our marriage by gift by inheritance other.: . Part E. Grounds for Dissolution of Marriage 1. My grounds for Dissolution of my marriage are: (Check all that apply) a. Irreconcilable Differences (separated in excess of 2 years) From on or about __ , my spouse and I have lived separate and apart from mmddyyyy each other for a continuous period in excess of 2 years and irreconcilable differences have caused the irretrievable breakdown of the marriage. Efforts at reconciliation have failed or future attempts at reconciliation would be impracticable and not in the best interests of the family. b. Irreconcilable Differences (separated in excess of 6 months with 2 year waiver) From on or about , my spouse and I have lived separate and apart from mmddyyyy each other for a continuous period in excess of 6 months and we have signed written waivers of the 2 year period of separation. Irreconcilable differences have caused the irretrievable breakdown of the marriage. Efforts at reconciliation have failed or future attempts at reconciliation would be impracticable and not in the best interests of the family. c. Physical or Mental Cruelty That without cause or provocation on my part, my spouse during the marriage has been guilty of extreme and repeated physical and/or mental cruelty. American LegalNet, Inc. www.USCourtForms.com Page 3 of 4 174-CSR200 (Rev 09/04) d. Other Grounds per 750 ILCS 5/401 (Please specify) Part F. Parties' Agreements 1. The parties have reached agreement(s) on the following issues: custody, visitation, child support or maintenance (support for a spouse) State the specific arrangements: . (Attach additional pages as needed) Part G. Relief Requested 1. FOR THESE REASONS, I request that judgment be entered that provides as follows: (Check all that apply) a. That the marriage be dissolved. b. That sole custody of the minor child(ren) be awarded to Petitioner c. That joint legal custody of the minor child(ren) be awarded with to be the residential custodian. d. That visitation with the minor child(ren) be granted Respondent. Petitioner restricted Respondent barred reserved. e. That child support be awarded. f. That a fair division of the property or its value acquired during the marriage be divided in just proportions. g. That maintenance to the Petitioner be h. That maintenance to the Respondent be granted granted waived barred reserved reserved i. That a change back to my former name: be granted. Full Former Name j. That any other appropriate relief be awarded. Under penalties as 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. Date Signature Printed Name * - Any person who makes a false statement, material to the issue or point in question, which he does not believe to be true, in any document certified by such person in accordance with 735 ILCS 5/1-109 shall be guilty of a Class 3 felony punishable by two (2) to five (5) years imprisonment and/or a $10,000.00 fine. Distribution: (3 Copies) Original to Circuit Clerk Petitioner Page 4 of 4 Respondent American LegalNet, Inc. www.USCourtForms.com 174-CSR200 (Rev 09/04)