===== PAGE 1 ===== # STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17th JUDICIAL CIRCUIT COUNTY, ILLINOIS Petitioner VS. CASE NO.___ Respondent ## CHILD SUPPORT DATA SHEET Pursuant to Local Rule 14.075, 17th Judicial Circuit, the following form must be completed and filed: 1. In new cases or when modifying an existing order, at time of filing petition or response; 2. In pending cases, within 15 days after receiving Child Support Data Sheet from Clerk. (Data sheet mailed by Clerk
PETITIONER INFORMATIONRESPONDENT INFORMATION
Last Name First Middle InitialLast Name First Middle Initial
Complete \textbf{Residential} Address:Complete \textbf{Residential} Address:
Complete \textbf{Mailing} Address: (If other than above)Complete \textbf{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
LASTFIRSTMIDDLE INITIALDATE OF BIRTHSOCIAL SECURITY #
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Submitted by: ___ _____ (Print or type name) Signature_ A-25 □ Petitioner □ Respondent Date:_____