Rev. 3/2019 1 IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT ROCK ISLAND COUNTY, ILLINOIS ) ) Petitioner, ) ) ) CASE NO. ) ) Respondent. ) CHILD CUSTODY AFFIDAVIT I, , the herein, being first duly sworn upon my oath, depose and state that the following information is true and correct to the best of my knowledge and as I verily believe: 1. This Affidavit is made in compliance with the Uniform Child-Custody Jurisdiction and Enforcement Act, 750 ILCS 36/101, et. seq. and in particular, Section 36/209 and 750 ILCS 5/601. 2. That there is/are minor child (ren) of this marriage, namely: NAME AGE 3. That the minor child(ren) presently reside at with . 4. Within the last five (5) years the minor child(ren) have resided at the following addresses with the following custodial parent: 5. That the (has)/(has not) participated as a party, witness or in any other capacity in other proceeding concerning the custody of, or visitation with, the same child(ren). a. Court in which proceeding was heard: . b. Case #: . c. Date of child custody determination: . 6. That the (knows/does not know) of any proceeding that could American LegalNet, Inc. www.FormsWorkFlow.com Rev. 3/2019 2 affect the current proceeding, including proceedings for enforcement and proceedings relating to domestic violence, protective orders, termination of parental rights and adoptions. a. Court in which proceeding was heard: . b. Case #: . c. Nature of the proceeding: . 7. That the (knows/does not know) the names and addresses of any person not a party to the proceeding who has physical custody of the child(ren) or claims rights of legal custody or physical custody of, or visitation with, the child(ren). a. Name: . b. Address: . . Dated this day of , 20. CERTIFICATE OF SERVICE Under the penalties as provided by law, pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the foregoing instrument was served upon all parties to the above cause and/or to each to the attorneys of record herein at the address(es) or email address(es) listed above (be sure to list the names and addresses above) on (insert time and date you served this notice). CHECK AT LEAST ONE: at least 4 court days prior to hearing - in the U.S. mail with proper postage prepaid at (insert city & state where you deposited it in the U.S. Mail.) at least 3 court days prior to hearing - to a third-party commercial carrier or courier with proper delivery charge prepaid at (insert city & state in which you gave it to a third-party commercial carrier or courier.) - at least one court day prior to the hearing - delivered by (insert name of person who made delivery) to (insert time and location of delivery.) (insert name of person sending email.) (Sign your name here) American LegalNet, Inc. www.FormsWorkFlow.com