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
| LAST | FIRST | MIDDLE INITIAL | DATE OF BIRTH | SOCIAL SECURITY # |
|---|
| 1. | | | | |
| 2. | | | | |
| 3. | | | | |
| 4. | | | | |
| 5. | | | | |
Submitted by: ___ _____
□ Petitioner □ Respondent Date:_____
(Print or type name)
Signature_
A-25