IN THE CIRCUIT COURT OF THE TWENTY-SECOND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS IN RE THE MARRIAGE OF ___________________________________ Petitioner vs. Case Number_________________________ ___________________________________ Respondent DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION ACT (UCCJA) UNIFORM CHILD CUSTODY JURISDICTION ENFORCEMENT ACT (UCCJEA) 1. _____________________________________ Attorney’s Name ________________________ 2. Number of minor children subject to this proceeding: __________________________________ Additional list attached. (Provide requested information for additional children on an attachment.) Insert the information requested below. The residence information must be given for the last five years. Child One Child Two Child Three Child’s Name and Sex Date of Birth Place of Birth Child’s Current Address and Length of Residence Name, Present Address and Relationship to Child of Person that lived at current address Child’s Previous Address and Dates of Residence Name, Present Address and Relationship to Child of Person that lived at 1st previous address Child’s Previous Address and Dates of Residence Name, Present Address, and Relationship to Child of Person that lived at 2nd previous address. Page 1 of 2 CV-DEC1 (Revised 4/26/07) American LegalNet, Inc. www.FormsWorkflow.com 3. Have you participated as a party, witness or in some other capacity in another litigation or custody proceeding, either in Illinois or elsewhere, concerning custody of a child subject to the proceeding? Yes No If yes, please provide the following information: A. Name of each child: ______________________________________________________ B. Capacity of declarant: Party Witness Other (specify) _________________ C. Court of Proceedings: (Specify Name, State, Location) ___________________________ ________________________________________________________________________ D. Date of Final Order or Judgment _____________________________________________ 4. Do you have information about a custody proceeding pending in an Illinois court or any other court concerning a child subject to this proceeding, other than that stated in item 3? Yes No If yes, please provide the following information: A. Name of each child: ______________________________________________________ B. Nature of proceeding: Dissolution of Marriage Guardianship Adoption Other (Specify)________________________________________ C. Court of Proceedings: (Specify Name, State, Location) ___________________________ ________________________________________________________________________ D. Status of proceeding: ______________________________________________________ ________________________________________________________________________ 5. Do you know of any person who is not a party to this proceeding who has physical custody, or claims to have custody of, or visitation rights with any child subject to this proceeding? Yes No If yes, please provide the following information: Name and Address of Person Name and Address of Person Name and Address of Person Has physical custody Claims custody rights Claims visitation rights Has physical custody Claims custody rights Claims visitation rights Has physical custody Claims custody rights Claims visitation rights Name of each child Name of each child Name of each child I declare under penalty of perjury under the laws of the State of Illinois that the foregoing is true and correct. _____________________________________ ____________________________________________ (Type or print name) (Signature of Declarant) Date ________________________________ Page 2 of 2 CV-DEC1 (Revised 4/26/07) American LegalNet, Inc. www.FormsWorkflow.com