Free IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT - Illinois

IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT ______________________________ COUNTY, ILLINOIS

IN RE THE MARRIAGE OF:

Petitioner, and

Respondent. STATE OF ILLINOIS ) ) COUNTY OF _________ )

) ) ) ) ) ) ) ) )

NO._____________ CHILD CUSTODY AFFIDAVIT

SS.

I, __________________, the __________________________ herein, being first duly sworn upon my oath, depose and state that the following information is true and correct to the best of my knowledge and as I verily believe: 1. This Affidavit is made in compliance with the Uniform Child-Custody Jurisdiction and Enforcement Act, 750 ILCS 36/101, et. seq. and in particular, Section 36/209 and 750 ILCS 5/601. 2. That there is/are ________ minor child (ren) of this marriage, namely: NAME AGE

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 3. That the minor child(ren) presently reside at ______________________________ _______________________________________________________________________________________ with _____________________________ .

4. Within the last five (5) years the minor child(ren) have resided at the following addresses with the following custodial parent: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 5. That the __________________________ (has)/(has not) participated as a party, witness or in any other capacity in other proceeding concerning the custody of, or visitation with, the same child(ren). a. Court in which proceeding was heard: ____________________. b. Case #: ________________. c. Date of child custody determination: _____________________.

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6. That the ________________________ (knows/does not know) of any proceeding that could affect the current proceeding, including proceedings for enforcement and proceedings relating to domestic violence, protective orders, termination of parental rights and adoptions. a. Court in which proceeding was heard: ____________________. b. Case #: ________________. c. Nature of the proceeding: _______________________. 7. That the _______________________ (knows/does not know) the names and addresses of any person not a party to the proceeding who has physical custody of the child(ren) or claims rights of legal custody or physical custody of, or visitation with, the child(ren). a. Name: _______________________. b. Address: _____________________. _____________________.

Dated this _______ day of ____________________________, 20________.

_______________________________________

SUBSCRIBED AND SWORN to be before me this ______ day of _________________________, 20_______. __________________________________ NOTARY PUBLIC _______________________signature Name of Attorney or party Address Phone number PROOF OF SERVICE The undersigned certifies that the foregoing instrument was served upon all parties to the above entitled cause by depositing a copy in the U.S. Mail postage prepaid in envelopes addressed to each of the attorneys of record or to the parties at the addresses shown below on the ________ day of ___________________, 20_______ by depositing the same in the U.S. Mail at ____________________in the County of _________________ and State of _________________. COPIES TO: ____________________________ _________________________________ _________________________________ _________________________________
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2-15-06 Version
Effective 7-1-06