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Affidavit Of Visitation Supervisor Form. This is a Illinois form and can be use in Lake Local County.
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Tags: Affidavit Of Visitation Supervisor, Illinois Local County, Lake
IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT,
LAKE COUNTY, ILLINOIS
)
)
)
_____________________________________ )
Petitioner )
vs.
)
)
_____________________________________ )
Respondent
General No. ____________________
AFFIDAVIT OF VISITATION SUPERVISOR
I, __________________________________________, state as follows:
1. I reside at:
(Print Name)
(Street Address, City, State, Zip)
2. My telephone number is:
3. My relationship to the parties is:
4. I accept the responsibility to supervise the visitation of ________________________ pursuant
to the order of this court dated ____________________.
5. My signature on this affidavit certifies that I will require that the visiting parent follow these
rules of conduct:
a. No discussion with the child(ren) about the divorce and/or any petition for order of protection.
b. No discussion with the children about the custodial parent’s activities.
c. No use of alcohol or drugs.
d. No abusive language.
e. No hitting or striking.
f. No physical discipline.
g. No threatening behavior.
6. I will cancel the visitation session if the visiting parent arrives for visitation under the influence
of alcohol or drugs.
7. I will terminate a visitation session if, at any time, it is necessary to protect the child(ren)’s best
interests.
8. I acknowledge my responsibility to account to the court for compliance with the Order for
supervised visitation.
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.
_________________________________
Dated this ____ day of __________________,20____
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.
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