Confidential Disclosure Statement Of Petitioner-Respondent
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Confidential Disclosure Statement Of Petitioner-Respondent Form. This is a Illinois form and can be use in Rock Island Local County.
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Tags: Confidential Disclosure Statement Of Petitioner-Respondent, Illinois Local County, Rock Island
STATE OF ILLINOIS
COUNTY
) IN THE CIRCUIT COURT OF THE FOURTEENTH
) JUDICIAL CIRCUIT _________ COUNTY, ILLINOIS
)
IN RE THE MARRIAGE OF:
)
)
)
)
)
NO.
)
) Pursuant to Local Rule this
) document to be filed under seal.
Petitioner,
and
Respondent.
CONFIDENTIAL DISCLOSURE STATEMENT
OF PETITIONER/RESPONDENT
HUSBAND
WIFE
Name: ______________________
Address: ____________________
____________________________
Soc. Sec. # __________________
Date of Birth:_________Age:____
Employer:____________________
Employer Address ______________
______________________________
Occupation:_____________________
Name: _____________________
Address:_____________________
___________________________
Soc Sec.#______________________
Date of Birth:_________Age:_______
Employer:______________________
Employer Address________________
_______________________________
Occupation:_____________________
CHILDREN OF THIS MARRIAGE/RELATIONSHIP
NAME
_______________
_______________
_______________
NAME
___________
___________
Date of Birth
__________
__________
__________
Age
___
___
___
OTHER CHILDREN
Date of Birth Age With Whom Residing
__________ ___ __________________
__________ ___ __________________
With Whom Residing
_________________
_________________
_________________
Other Case Number
________________
________________
KNOWN MEDICAL CONDITIONS OF PARTIES/ CHILDREN
________________________________________________________________________
________________________________________________________________________
1
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I, the undersigned, declare and certify pursuant to 735 ILCS 5/2-1009, under penalties of
perjury, that the foregoing, including any attachments, is a true and correct to the best of
my knowledge, information and belief, and that I executed this on the ______________
day of _______________________________, 20_______.
_____________________________
SUBSCRIBED AND SWORN to before me this ________________ day of
___________________, 20_________.
_____________________________
NOTARY PUBLIC
BY: _____________________________
Attorney
Attorney Name
Attorney Address
Attorney Phone Number:
2
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