This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois courts. DV - CSIS 128.1 Page 1 of 2 ( 04 / 1 8 ) STATE OF ILLINOIS, SUPPORT INFORMATION SHEET (To Be Impounded by the Circuit Clerk to Protect Private Information) For Court Use Only CIRCUIT COURT COUNTY Instruction s Enter above the county name where you will file this case. Enter the full name of Petitioner, Respondent, and the case number as listed on the Petition for Dissolution of Marriage/Civil Union (Divorce with Children ). Petitioner (First, middle, last name) IV - D Case Number v. IL Department of Healthcare and Family Services is granted leave to intervene Respondent (First, middle, last name) Case Number Enter the IV-D case number if you know it. In 1, enter Petitioner's information. 1. I am providing the following information about Petitioner : a. Name: First Middle Last b. Address : Street , Apt # City State ZIP c. Date of Birth: d. Social Security Number: e . Phone Number : f. I am employed by: Employer Name Employer Address: Street , Apt # City State ZIP Employer Phone Number: g. I am also employed by: Employer Name Employer Address: Street , Apt # City State ZIP Employer Phone Number: In 2, enter Respondent's information. 2 . I am providing the following information about Respondent : a. Name: First Middle Last b. Address : Street , Apt # City State ZIP c. Date of Birth: d. Social Security Number: e . Phone Number : f. Respondent is employed by: Employer Name Employer Address: Street , Apt # City State ZIP Employer Phone Number: American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: DV - CSIS 128.1 Page 2 of 2 ( 0 4 / 1 8 ) g. Respondent is also employed by: Employer Name Employer Address: Street , Apt # City State ZIP Employer Phone Number: In 3, list the names and birthdates of the children for whom support was ordered. Leave blank if no child support was ordered. 3. I am providing the following information about the children for whom support was ordered: Name Date of Birth 1. 2. 3. I have listed additional minor children on the attached Additional Minor Children This form was prepared by: If you are completing this form on a computer, sign your name by typing it. If you are completing it by hand, sign and print your name. /s/ Your Signature Street Address Your Name City, State, ZIP If you e-file this form, select "confidential" when uploading the form. Telephone American LegalNet, Inc. www.FormsWorkFlow.com