This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts. STATE OF ILLINOIS , CIRCUIT COURT COUNTY ADDITIONAL DEBTS & LIABILITIES (DISSOLUTION OF MARRIAGE/CIVIL UNION) For Court Use Only Instructions P etitioner ( First, middle, last name ) Directly above, enter the county where you filed this case. Enter your name as Petitioner . Enter the name of your spouse/partner as Respondent. v. Respondent ( First, middle, last name ) Case Number Enter the Case Number given by the Circuit Clerk. DO fill in the name of creditor and amount owed for debts after the date of marriage/civil union in the chart. DO NOT check who is to pay the debt. Additional Debts and Liabilities Debt (Name of Creditor) Amount Owed To be paid by : Petitioner Respondent Both Equally 1. $ 2. $ 3. $ 4. $ 5. $ 6 . $ 7 . $ 8 . $ 9. $ 10. $ 11. $ 12. $ 13. $ 14. $ 15. $ 16. $ 17. $ 18. $ 19. $ 20. $ 21. $ 22. $ DV - AD 109.3 Page 1 of 1 ( 09 / 18 ) American LegalNet, Inc. www.FormsWorkFlow.com