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STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17th JUDICIAL CIRCUIT COUNTY, ILLINOIS

Petitioner VS. CASE NO.___

Respondent

CASE NO.

Pursuant to Local Rule 14.075, 17th Judicial Circuit, the following form must be completed and filed:

In new cases or when modifying an existing order, at time of filing petition or response;
In pending cases, within 15 days after receiving Child Support Data Sheet from Clerk. (Data sheet mailed by Clerk

PETITIONER INFORMATION	RESPONDENT INFORMATION
Last Name First Middle Initial	Last Name First Middle Initial
Complete extbf{Residential} Address:	Complete extbf{Residential} Address:
Complete extbf{Mailing} Address: (If other than above)	Complete extbf{Mailing} Address: (If other than above)
Date of Birth:	Date of Birth
Driver's License No.:	Driver's License No.:
Social Security No.:	Social Security No.:
Home Phone Number: [ ]	Home Phone Number: [ ]
Employer(s) Name/Company:	Employer's Name/Company:
Employer(s) Address:	Employer(s) Address:
Employer(s) ID Number:	Employer(s) ID Number:
Work Phone Number: [ ]	Work Phone Number: [ ]

CHILD/CHILDREN INFORMATION

Submitted by: ___ _____

□ Petitioner □ Respondent Date:_____

(Print or type name)

Signature_ A-25