Free Divorcing Parents of Minors – Children First Program (PDF) - Illinois


File Size: 350.0 kB
Pages: 23
Date: December 30, 2008
File Format: PDF
State: Illinois
Category: Court Forms - Local
Author: MADISON COUNTY
Word Count: 6,819 Words, 49,661 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.co.madison.il.us/CircuitClerk/PDF/DivorcingParentsOfMinors09.pdf

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Notice to Those Seeking Dissolution of Marriage: Besides the attached entry of appearance and military service affidavit forms, you will also need to complete and file 1) a Petition for Dissolution of Marriage and 2) a Judgment for Dissolution of Marriage (original and two copies). To learn more about how to prepare a petition and judgment for dissolution of marriage, information is available from the law library in the basement of the courthouse. For standard dissolutions of marriage, there is a $219.00 filing fee paid to the Circuit Clerk's office when the case is filed, and a $119 answer fee paid by the respondent. For joint simplified dissolutions (that is, when both parties file jointly for dissolution and there are no children are involved), the filing fee is $219 and no answer fee is required. For more information and eligibility for joint simplified dissolutions, click on "Divorce ­ Information and Forms" at the previous page. If you have children under the age of 18, you must enroll in the Children First Program before your judgment can be entered. To sign up for the program, call 618-251-6214. You may file your petition and all pleadings Monday through Friday, from 8:30 am to 4:00 pm, in the Circuit Clerk's office. When you file your petition, you will be advised when you will have to see the judge again. **Circuit Clerk employees may answer general questions but are prohibited from assisting in preparation of documents**

Dear Parents with Minor Children: Children First is a program mandated by the Illinois Supreme Court and the Third Judicial Circuit (Madison and Bond counties) to benefit divorcing parents of children under the age of 18. (Scroll down to the next page for further information about Children First.) All parties shall attend and complete the Children First program as soon as possible. The court may not enter a final custody order unless one or both parties have attended Children First. The mission of Children First is to help you understand more about the impact of divorce on your children, and how to reduce damaging effects of divorce on them. The program helps you to help your children cope with the changes divorce brings to their lives. The intention of Children First is to be sensitive to your problems and needs at a difficult time in your life, and to be as helpful and supportive as possible to you.

CHILDREN FIRST
Parenting Education
For Divorcing Parents of Minors
Children First Foundation, Inc.

About the Children First Parenting Education Program
If you have children under the age of 18, you must enroll in the Children First Parenting Education Program before a divorce will be granted by the Third Judicial Circuit Courts (Madison and Bond counties). That is, a divorce judgment will not be entered until you enroll in and attend both sessions (two hours each, totaling four hours) of the Children First Parenting Education Program. A certificate will be presented to you at the end showing proof of completion. The goals of the Children First Parenting Education Program are to increase participants' awareness of divorce on children's feelings and behaviors, and increase participants' knowledge in how to assist the children in coping and adjusting. Attending the four-hour class meets the court mandated parenting education requirement for divorcing parents in Illinois. You will be reminded to put your "children first."

How to Enroll
To register for both sessions of the Children First Parenting Education Program, call 618-2516214 between 9am and noon, Monday through Friday. If you call at another time you may get an answering service. If you do, please leave a message speaking slowly and clearly, stating your name and a phone number where you can be reached. Mention that you need to register for the Children First class. You will be called the next business day.

Schedule
Monday evenings: Tuesday evenings: 6-8 pm 6-8 pm Session I Session II

Location
Kids' Corner, Madison County Facility (former Wood River Hospital, east side of building, enter door "B" off parking lot) 101 East Edwardsville Road Wood River, Illinois 62095 Phone number: 618-251-6214

Cost
The price for the four-hour class is $50 (fifty dollars). The cash payment is due at the first session (Monday) before class. Checks are not accepted. Waivers by the Court are accepted for

individuals whose income qualifies them for a fee exception. The waivers must be presented at the first session (Monday) by the participant. For income eligibility information and Affidavit and Application To Sue or Defend as an Indigent Person form, which can be printed and presented to the Court, scroll down.

Instructions
$Divorcing parents will not be scheduled for the same sessions. $Do not bring children to the sessions. You will be asked to leave. $Do not bring unregistered adults to the sessions. $Both parents must attend classes and get their own certificates of completion.

What to Expect from Sessions I and II
Session I: Video and guided discussion by Master-degreed moderator dealing with topics such as: 1. Disagreements in front of children 2. Using children as leverage 3. Competition between parents 4. Negative comments about the other parent 5. Discipline and behavior changes 6. Substance use and abuse 7. New relationships and adult coping 8. New relationships and children coping 9. Creating quality time 10. Missed visitations 11. "Interrogating" the children 12. Change vs. loss for the children 13. Abandonment feelings Guided discussion will investigate better alternatives for parents Session II: Video, guided discussion by Master-degreed moderator, helpful brochures and handouts for future reference: 1. Normal child developmental stages 2. Awareness of how divorce affects children's behaviors/feelings 3. Assisting children in coping and adjusting 4. Warning signs of serious problems in children 5. Risk and protective factors that impact children 6. How children react 7. Children discussing custody and divorce ("Kids Helping Kids") 8. Asset development in children 9. Available area services 10. Mediation: process, video presentation and discussion

Conflicts between parents often continue well beyond court litigation. When conflict exists, it can cause long-term suffering for children. Given information and guidance from the Children First Parenting Education sessions, parents can move beyond their differences and put the best

interest of their "children first" by anticipating and avoiding potential for future problems. Birthdays, holidays, vacations, school events, visitation and numerous co-parenting decisions must be anticipated and planned for. Children are often the silent victims in cases of divorce, visitation and custody dispute. These sessions recognize the importance of parent-child relationships, and promote continued healthy co-parenting skills.

AFFIDAVIT AS TO MILITARY SERVICE

(Petitioner) vs Case Number (Respondent) AFFIDAVIT AS TO MILITARY SERVICE OF RESPONDENT I, 1. 2. , make oath and say as follows: My age is years, my residence is at and my occupation is . I am the petitioner in the above-entitled action and as such have full knowledge of the facts relating thereto. (Check A., B. or C.) A. Said respondent is in the military service of the United States. B. Said respondent is not in the military service of the United States. C. I am not able to determine whether or not respondent is in such service. D. I further state that

(In D., set forth the fact upon which affidavit is based. The Soldiers and Sailors Civil Relief Act requires facts be stated showing respondent is not in the military service. Stating conclusion only is not sufficient. If respondent is in the military service, file date of induction, unit, and length of service, if known.)

(Petitioner)

SUBSCRIBED AND SWORN TO ME THIS , A.D., 200 .

DAY OF

.

NOTARY PUBLIC

ENTRY OF APPEARANCE ­ WAIVER AND CONSENT STATE OF ILLINOIS COUNTY OF MADISON IN RE THE MARRIAGE OF: ) ) )

SS.

IN THE CIRCUIT COURT

CASE NUMBER PETITIONER
AND

RESPONDENT I HEREBY ENTER MY APPEARANCE IN THE ABOVE-ENTITLED CAUSE AS RESPONDENT HEREIN, AND EXPRESSLY WAIVE THE NECESSITY OF PROCESS OF SUMMONS AND CONSENT THAT THE SAME PROCEEDINGS MAY BE HAD HEREIN, AS FULLY AND WITH THE SAME FORCE AND EFFECT AS THOUGH I HAD BEEN DULY AND REGULARLY SERVED WITH PROCESS OF SUMMONS THEREIN IN THE STATE OF ILLINOIS, AT LEAST THIRTY DAYS PRIOR TO ANY RETURN DAY DESIGNATED BY THE PETITIONER HEREIN OR AS PROVIDED BY LAW. I FURTHER CONSENT THAT IMMEDIATE DEFAULT MAY BE TAKEN AND ENTERED HEREIN AGAINST ME UPON THE FILING OF
THIS APPEARANCE OR AT ANY TIME THEREAFTER AND THAT AN IMMEDIATE HEARING OF SAID CAUSE MAY BE HAD WITHOUT FURTHER NOTICE.

DATED AT 200 .

, ILLINOIS THIS

DAY OF

, A.D.,

STATE OF ILLINOIS

) ) COUNTY OF MADISON )

SS.

I, A NOTARY PUBLIC IN AND FOR SAID COUNTY IN THE STATE AFORESAID, DO HEREBY CERTIFY THAT PERSONALLY KNOWN TO ME TO BE THE SAME PERSON WHOSE NAME IS SUBSCRIBED TO THE WITHIN INSTRUMENT OF WRITING, APPEARED BEFORE ME THIS DAY IN PERSON, AND ACKNOWLEDGED THAT SIGNED THE SAME AS FREE AND VOLUNTARY ACT, FOR THE USES AND PURPOSES THEREIN SET FORTH. GIVEN UNDER MY HAND AND NOTARIAL SEAL, THIS .
DAY OF

, A.D.,

200

NOTARY PUBLIC

ORDER/NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT State of Illinois County of Madison Date of Order/Notice Court Number: ( ( (
Payor/Withholder's Federal EIN Number Payor/Withholder's Name Payor/Withholder's Address AND any subsequent Payor of Income: Child's Name and DOB: Child's Name and DOB:

) Original Order/Notice ) Amended Order/Notice ) Terminated Order/Notice
RE: ) ) ) ) ) (Employee/Obligor's Name: First, Last, MI) Employee/Obligor's SS#: Employee/Obligor's Case Identifier: Custodial Parent's Name: Child's Name and DOB: Child's Name and DOB:

ORDER INFORMATION: This is an Order/Notice to Withhold Income for Child Support based upon an order for support from . By law, you are required to deduct these amounts from the above-named employee's/obligor's income until , even if the Order/Notice is not issued by your State. ( ) If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. $ $ $ $ $ / / / / / in current support payable every two weeks in past-due support totaling $ in medical support on a total delinquency of $ as of in to be forwarded to the payee below

Arrears 12 weeks or greater? ( ) yes

( ) no

For a total of

You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ $ per weekly pay period per bi-weekly pay period (every 2 weeks) $ $ per semimonthly pay period (twice a month). per monthly pay period.

REMITTANCE INFORMATION: Follow the laws and procedures of the employee's/obligor's principal place of employment even if such laws and procedures are different from this paragraph: You must begin withholding no later than the first pay period occurring 14 working days after the date of this Order/Notice. Send payment within 7 working days of the pay date/date of withholding. You are entitled to deduct a fee of your actual cost not to exceed $5 monthly to defray the cost of withholding. The total withheld amount, including your fee, cannot exceed 65% of the employee/obligor's aggregate disposable weekly earning. For the purpose of the limitation on withholding, the following information is needed (see #9 on back): When remitting payment provide the pay date/date of withholding, the Court/Case Number . If remitting by EFT/EDI, use this FIPS code: N/A ; Bank routing code: Make checks payable to and send to: and the case identifier N/A ; Bank account number: N/A .

State Disbursement Unit P.O. Box 5400 Carol Stream, IL 60197 Authorized by: Print Name:
D PA 3683 (7/97)

Court Case:

and Case Identifier:

Page 1 of 2

IL4782408

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
( 1. ) If checked, you are required to provide a copy of this form to your employee.

Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please contact the requesting agency listed below. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment, the paydate/date of withholding is the date on which the employee is paid and controls the income, i.e., the date the income check or cash is given to the employee, or the date in which the income is deposited directly in his/her account. Employee/Obligor with Multiple Support Withholdings: If you receive more than one Order/Notice against this employee/obligor and you are unable to honor them all in full because together they exceed the withholding limit of the State of the employee's principal place of employment (see #9 below), you must allocate the withholding based on the law of the State of the employee's principal place of employment. If you are unsure of that State's allocation law, you must honor all Orders/Notices' current support withholding before you withhold for any arrearages, to the greatest extent possible under the withholding limit. You should immediately contact the last agency that sent you an Order/Notice to find the allocation law of the state of the employee's principal place of employment. Termination Notification: You must promptly notify the payee when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this order/notice to the agency identified below. EMPLOYEE'S/OBLIGOR'S NAME: EMPLOYEE'S CASE IDENTIFIER: LAST KNOWN HOME ADDRESS: DATE OF SEPARATION:

2.

3.

4.

5.

6.

NEW PAYOR'S (OF INCOME) NAME AND ADDRESS: Lump Sum Payments: You may be required to report and withhold from lump-sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump-sum payments, contact the person or authority below. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and any other penalties set by State law. You may be found liable for the total amount which you failed to withhold or pay over and fines up to $100.00 per day for each day after the grace period. In Illinois, subsection (G) of 305 ILCS 5/10-16.2, 750 ILCS 5/706.1, 750 ILCS 15/4.1 or 750 ILCS 45/20. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of child support withholding.

7.

8.

9.

Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (1 5 U.S.C. § 1673(b)); or 2) the amount allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. The Federal CCPA limit is 50% of the ADWE for child support and alimony, which is increased by: 1) 10% if the employee does not support a second family; and/or 2) 5% if arrears are more than 12 weeks old (see boxes on front). Obligor's Rights: For the obligor's rights, remedies and duties, see Illinois Statutes 305 ILCS 5/10-16.2, 750 ILCS 5/706.1, 750 ILCS 15/4.1 and 750 ILCS 45/20. Requesting Agency: Madison County Circuit Clerk 155 North Main Street Edwardsville, IL 62025 Page 2 of 2 If you or your employee/obligor has any question, contact the Child Support Section of the Circuit Clerk at telephone (618) 692-6250 or FAX (618) 692-8904 IL 4782408 Case No. ________________

10.

DPA 3683 (7/97)

Document Handbook Instructions for Completing DPA 3683, Order/Notice to Withhold Income for Child Support

CSE

The Order/Notice to Withhold Income for Child Support is a standardized form used for income withholding in intrastate and interstate cases. Submit the Order/Notice to employers in States that have adopted the Uniform Interstate Family Support Act (UIFSA) or have similar State laws. The following are instructions to complete the Order/Notice to Withhold Income for Child Support. When completing the form, please include the following information.
Item 1 2 3 Description Name of your county. Date the Order/Notice to Withhold is to be mailed. Tribunal number (administrative or docket) used by the court/agency issuing this Order/Notice, if appropriate. Check the appropriate case status of the Order/Notice to Withhold: a. original (or) b. amended (or) c. terminate Employer/Withholder's nine-digit Federal Employer Identification Number (FEIN), if available. Include three-digit location code, if known. Employer/Withholder's name

4

5

6a

6 b-d. Employer/Withholder's mailing address (may differ from the Employee/Obligor work site). 6e This entry ensures that if the employee changes jobs, this Notice can be served on the "subsequent employer." Employee/Obligor's last name, first name and middle initial (if known). Employee/Obligor's Social Security number. IV-D number used for recording the payment (may be the same as #3.) Custodial parent's last name, first name and middle initial (if known). Child(ren)'s name(s) and date(s) of birth as listed in the support order. Name of state that issued the underlying (original jurisdiction) child-support order. Termination date of the support order. Check if the child-support order requires enrollment of the child(ren) in any health insurance coverage available through the employee's/obligor's employment. If the obligor is a Federal

7 8 9 10 11 12 13 14

INCOME WITHHOLDING DOCUMENT #38

Item

Description government employee, please do not check the box provided. The space is provided for instructions (i.e., see attached form).

15a.

Dollar amount to be withheld for payment of current child support. If no current support is ordered enter the word "none." Time period (frequency due) that corresponds to the amount in #15a (e.g., month). Dollar amount to be withheld (including frequency due) for payment of past-due child support under State law (if a dollar amount is involved pursuant to a Notice of Delinquency or an established arrearage). If none is ordered, enter the word "none." If additional space is needed, go to item 18 or 19. Time period (frequency due) that corresponds to the amount in 16a (e.g., month). Total amount of past-due support. For medical support, as appropriate, based on the underlying order enter the work "premium." If none is ordered, enter the word "none." Time period (frequency due) that corresponds to the amount in 17a (e.g., monthly, weekly or "premium schedule"). Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order. If none, enter the word "none." Time period (frequency due) that corresponds to the amount in 18a (e.g., month). Describe the delinquency amount(s) by adding the following statement on the blank line: $ per month on a total delinquency of $ . Dollar amount to be withheld for payment of miscellaneous obligations, if appropriate, based on the underlying order and time period that corresponds to the amount in 19a. Time period (frequency due) that corresponds to the amount in 19a (e.g., month). Describe the amount(s) represented in 19a separately by fee type (e.g., court fees). Total of 15a, 16a, 17a, 18a, and 19a. Time period (frequency due) that corresponds to the amount in 15b (e.g., month). Check this box if arrears are 12 weeks or greater. Amount an employer withholds if the employee is paid weekly. Amount an employer withholds if the employee is paid every two weeks.

15b. 16a.

16b 16c 17a

17b

18a

18b 18c

19a

19b 19c 20a 20b 21 22a 22b

INCOME WITHHOLDING DOCUMENT #38

Item 22c 22d 23 24

Description Amount an employer withholds if the employee is paid twice a month. Amount an employer withholds if the employee is paid once a month. Number of days in which the withholding must begin pursuant to the law of your State. Number of working days an employer or other payor of income must remit amounts withheld pursuant to the law of your State. Maximum percentage that can be withheld based on the applicable withholding limit of your State. If the employer is a Federal agency and you add the additional five percentage points allowed under the Federal Consumer Credit Protection Act to the percentage entered for #22 (i.e., 65%; or 55% instead of 50% if the obligor supports a second family), check #14c on the Order/Notice to indicate the support is 12 weeks or more in arrears. IV-D number or other identifier (may be the same as #3 and/or #9). Federal Information Process Standard (FIPS) code for transmitting payments through EFT/EDI. The FIPS code is five characters and identifies the State and county. It is seven characters when it identifies the State, county and a location within the county. It is necessary for centralized collections. Complete only for EFT/EDI transmission. Receiving agency's bank routing number, to be completed only for EFT/EDI transmission. Receiving agency's bank account number, to be completed only for EFT/EDI transmission. Name of child-support enforcement agency to which payments are made and the IV-D case number on payment line.

25

26a 26b

26c 26d 27a

27b-d Street address, city and state of the child-support enforcement agency identified in #28a. 28a Signature of official(s) authorized to send the Order/Notice. This line is optional if signature is not required by State statute. Print name of the official(s) authorized to send the Order/Notice. Name of attorney of record. Registration number for attorney of record. Check the box if the employer is to provide a copy of the Order/Notice to the employee. If you are serving this order out of the State of Illinois, this box must be checked. Penalty and your state citation for an employer that fails to comply with the Order/Ntoice. Your State law governs unless the obligor is employed in another state, in which case the law of the state in which he or she is employed. Name of the agency or court requesting the income withholding. INCOME WITHHOLDING DOCUMENT #38

28b 29a 29b 30

31

32a

Item 32b-e 33a

Description Address of the agency or court requesting the income withholding. Name of the child-support enforcement agency's contact person who an employer and/or employee/obligor may call for information regarding the Order/Notice. Telephone number of the contact person who an employer may call for information regarding the Order/Notice. Facsimile number for the person whose name appears in #35a. Internet address for the person whose name appears in #35a.

33b

33c 33d

If the employer is a Federal government agency, the following instructions apply: Serve the Order/Notice upon the governmental agent listed in 5CFR part 581, appendix A. Sufficient identifying information must be provided in order fro the obligor to be identified. It is, therefore, recommended that the following information, if known and if applicable, be provided: 1) full name of the obligor; 2) date of birth; 3) employment number, Department of Veterans Affairs claim number, or civil service retirement claim number; 4) component of the government entity for which the obligor works, and the official duty station or worksite; and 5) status of the obligor, e.g., employee, former employee, or annuitant. You may withhold from a variety of income and forms of payment, including voluntary separation incentive payments (buyout payments), incentive pay, and cash awards. For a more complete list, see 5 CFR 581.103. ******************************** The Paperwork Reduction Act of 1995

This information collection is conducted in accordance with 45 CFR 303.7 of the child-support enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case processing. Public reporting burden for this collection of information is estimated to average one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. This information is subject to State and Federal confidentiality requirements; however, the information will be filed with the tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Income Withholding Document #38

IN THE CIRCUIT COURT THIRD JUDICIAL CIRCUIT MADISON COUNTY, ILLINOIS PEOPLE OF THE STATE OF ILLINOIS ex rel. Plaintiff, vs. Defendant. ) ) ) ) ) ) )

Case No:

AFFIDAVIT OF ASSETS AND LIABILITIES I, 1. 2. 3. 4. 5. , a party in this case on oath states: Name , Date of Birth . Address , Phone . Family (a) Marital Status . (b) Number of Children (c) Number of Dependents . Earnings and sources of income: (a) $ (gross) per month from employment. (b) $ (gross) per month from pension, trusts, annuity, welfare, workers' compensation, retirement or disability plan, or any similar State, Federal, local or private benefit plan. (c) $ (gross) per month from rents, royalties, bonds, securities, or interest. (d) $ (gross) per month from other sources. Source(s) of other income . (e) $ (gross) per month from all sources. (f) $ (gross) total earnings and income per month.

6.

Value of Assets:
(a) (b) (c) (d) (e) (f) (g) (h) (i) (j) Home or other dwelling $ Other real property $ . ; where situated .

Car $ , Make Year Car $ , Make Year Other personal property (jewelry, household contents, furs, etc.) Bank accounts $ Cash on hand $ Surrender value of life or annuity insurance policies $ Securities, trusts, bonds $ Other asset(s) $ , described herein Total value of asset(s) $ . . . . . . . .

7.

AVERAGE MONTHLY EXPENSES: car payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ car insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ car license . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ gas, oil, repairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ rent or mortgage payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

AFFIDAVIT OF ASSETS AND LIABILITIES - page 2. AVERAGE MONTHLY EXPENSES: (continued) real estate taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . real estate insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . rental insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . electricity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . gas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . telephone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cable TV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . trash fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sewer fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hair cuts or beauty shop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . day care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . personal items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . credit card payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . loans - list name and amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

medical & hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . life insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . accident insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . school tuition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . school fees and expenses (including lunches) . . . . . . . . . . . . . . . . . . . . . . . . . . . . school extracurricular activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . other extracurricular activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . medical, doctor & dental bills - list name and amount(s):

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ entertainment expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ charitable contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ cleaning and laundry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Other - list below: $ $ TOTAL OF ABOVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

I certify that the information on the foregoing pages is true to the best of my knowledge and belief.

Case No. ____________

IN THE CIRCUIT COURT OF THIRD JUDICIAL CIRCUIT MADISON COUNTY, ILLINOIS UNIFORM ORDER FOR SUPPORT [ ] Initial Order [ ] Modification _________________________________________ ) Petitioner/Plaintiff ) ) vs. ) ) _________________________________________ ) Respondent/Defendant

Court Case No. _____________________________
Illinois Dept. of Healthcare & Family Services is, or has been, granted leave to intervene

HFS. No. __________________________

Definitions: Obligor ­ An individual who owes a duty to make support payments pursuant to an order for support. Obligee ­ An individual to whom a duty of support is owed or the individual's legal representative. Payor ­ Any payor of income to an obligor. Unallocated Support ­ A total amount for maintenance and child support and not a specific amount for either. The Court finds: a) The net income of the obligor as of the date of this order is $______________per ______________. b) The amount of arrearage as of the date of this order is $_________for child support and $________ for maintenance or unallocated support. c) The amount of child support cannot be expressed exclusively as a dollar amount because all or a portion of the obligor's net income is uncertain as to source, time of payment, or amount. It is ordered that ___________________________(Fill in Name), Obligor, is to provide: [ ] MAINTENANCE OR [ ] UNALLOCATED SUPPORT Payment Amount: Current Maintenance or Unallocated Support Payment: Arrearage Payment Payment Frequency: [ ] every week [ ] every other week [ ] monthly [ ] twice each month on ________&________ (date) [ ] every year [ ] other

$__________ $__________

Payments Begin: ___________________ (date) [ ] CHILD SUPPORT (Do not complete this section if Unallocated Support is ordered.) Payment Amount Current Child Support Payment: $_________ Arrearage Payment: $_________ Payment Frequency: [ ] every week [ ] every other week [ ] monthly [ ] twice each month on ________&________ (date) [ ] every year [ ] other

Payments Begin: ____________ (date)

Form approved by Conference of Chief Circuit Judges

Page 1 of 4

Revised 4/28/06

Case No.

[

]

PERCENTAGE AMOUNT OF CHILD SUPPORT

(Complete this section only if finding c) is checked on previous page.)

In addition to the specific dollar amount of support ordered above, current child support shall be paid in the amount of _______% of obligor's ___________________________________________________________ payable ______________________________________________. The obligor is further ordered to provide income records sufficient to determine and enforce the percentage amount of child support, within 7 days of receipt of income subject to this percentage assessment, to the obligee and Clerk of the Court [X] PAYMENT ARRANGEMENTS (Payments must be sent to the STATE DISBURSEMENT UNIT if this box is checked.) A Notice to Withhold Income shall issue immediately and shall be served on the employer at the address in this Order. Payments shall be made payable to the State Disbursement Unit and sent to the State Disbursement Unit at P.O. Box 5400, Carol Stream, IL 60197-5400. Payments must include CASE NUMBER, COUNTY of the Court issuing this Order, and obligor's name and social security number. Any subsequent employer may be served with a Notice to Withhold Income without further order of Court The parties have entered into a written agreement providing for an alternative arrangement for the payment of support that is approved by the Court and attached to this Order, meeting all requirements of, and consistent with, applicable law. An income withholding notice is to be prepared and served only if the obligor becomes delinquent in paying the order for support. Payments shall be made in accordance with the written agreement of the parties attached hereto. In the event the income withholding notice is served, payments shall be made to the State Disbursement Unit as set forth above. In addition to and separate from amounts ordered to be paid as maintenance or child support, the obligor shall pay a $36 per year Separate Maintenance and Child Support Collection Fee. This sum shall be paid directly to the Clerk of the Circuit Court of Madison County at 155 N. Main Street, Room 118, Edwardsville IL 62025 and not to the State Disbursement Unit. [X] DELINQUENCY

listed

If the obligor becomes delinquent in the payment of support after the entry of this Order For Support, the obligor must pay, in addition to the current support obligation, the sum of (a) $______________ for child support per the payment frequency ordered above for child support, and (b) $______________ for maintenance or unallocated support per the payment frequency ordered above for maintenance or unallocated support, until the delinquency is paid in full. (This additional amount, the total of (a) and (b), shall not be less than 20 percent of the total of the current support amount and the amount to be paid periodically for payment of any arrearage stated in the order for support.) A support obligation, or any portion of a support obligation which becomes due and remains unpaid for 30 days or more shall accrue interest at the rate of 9%, as set forth in Section 12-109 of the Code of Civil Procedure or as otherwise provided by law. Any portion of a support obligation that remains unpaid at the end of a month, excluding the support that became due for that month, shall accrue interest as provided in Section 12-109 of the Code of Civil Procedure.

Form approved by Conference of Chief Circuit Judges

Check Only One

Page 2 of 4

Revised 4/28/06

Case No. ________________

[X]

TERMINATION

This obligation to pay child support terminates on _______-_______-_______ unless modified by written order of the Court. (Insert a date no earlier than the date that the youngest child reaches the age of 18 or is expected to graduate from high school, whichever comes later.) This termination date does not apply to any arrearage that may remain unpaid on that date. The child/children covered by this order is/are: __________________________________________________________________________________________ __________________________________________________________________________________________ [ ] INSURANCE

The [ ] obligor, [ ] obligee, [ ] obligor and obligee, shall provide health insurance for the child(ren) either by [ ] enrolling them in any health insurance coverage available through the [ ] obligor's, [ ] obligee's, [ ] obligor's and obligee's, employment or [ ] securing a private health insurance policy, accepted by the obligor and obligee or approved by the Court, which names the child(ren) as beneficiary. Both the obligor and the obligee shall be provided a copy of the insurance policy and the insurance card. The name of the health insurance provider and the number of the insurance policy regarding dependent benefits/coverage on the date of this order as follows: Name of Health Insurance Provider(s): __________________________________________________ __________________________________________________ __________________________________________________ It is further ordered that: Policy No.(s): ____________________________________ ____________________________________ ____________________________________

The obligor shall give written notice to the Clerk of the Court, and if a party is receiving child and spouse services under Article X of the Illinois Public Aid Code, to the Department of Healthcare & Family Services, within 7 days, of: any new residential, mailing address or telephone number; the name, address and phone number of any new employer, and; the policy name and identifying number(s) of health insurance coverage available. The obligor shall submit a written report of termination of employment and of new employment, including name and address of the new employer, to the Clerk of the Court and the obligee within 10 days. Obligor and obligee shall advise each other of a change of residence within 5 days except when the Court finds that the physical, mental or emotional health of a party or that of a minor child, or both, would be seriously endangered by disclosure of the party's address. An obligee receiving payments through income withholding shall notify the Clerk of the Court and the State Disbursement Unit within 7 days, of a change in residence. The obligor and obligee shall report to the Clerk of the Court any change of information included in the Child Support Data Sheet (Exhibit 1) within 5 business days of such change.

[ ]

ADDITIONAL CONDITIONS OR FINDINGS

Child Support payment amount deviates from the amount required by statutory minimum guidelines. The amount of support that would have been required under the guidelines is $ ____________. Reasons for deviation:__________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Form approved by Conference of Chief Circuit Judges

Page 3 of 4

Revised 4/28/06

Case No. ________________

If there is an unpaid arrearage or delinquency equal to at least one month's child support obligation on the termination date, then the periodic amount required to be paid for current child support prior to the termination date shall automatically continue to be an obligation toward satisfaction of the unpaid arrearage or delinquency until paid in full. This payment shall be in addition to any periodic payment required for the satisfaction of the arrearage or delinquency which payments shall continue until such amounts are paid in full.

Other: ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ The "Child Support Data Sheet" attached hereto, as Exhibit 1, is a part of this Order. It is ordered the Clerk of the Court impound Exhibit 1 until further order of this Court.

FAILURE TO OBEY ANY OF THE PROVISIONS OF THIS ORDER MAY RESULT IN A FINDING OF CONTEMPT OF COURT

_______________________ Date

____________________________________________________ Judge

Prepared by:_________________________ Attorney for:_________________________ Address:____________________________ ___________________________________ Telephone:__________________________ Attorney No:________________________

Form approved by Conference of Chief Circuit Judges

Page 4 of 4

Revised 4/28/06

Case No.

PLAINTIFF/PETITIONER COUNTY_______________ vs. ___________________________ DEFENDANT/RESPONDENT CHILD SUPPORT DATA SHEET DATE__________________

OBLIGOR INFORMATION Last name: First Name: Complete Residential Address: Middle In.: Last name:

OBLIGEE INFORMATION

First name: Complete Residential Address:

Middle In.:

Complete Mailing Address (If other than above):

Complete Mailing Address (If other than above):

Date of Birth: Driver's License No.: *Social Security No.: Home Phone Number: ( ) Employer(s) Name/Company:

Date of Birth: Driver's License No.: Social Security No.: Home Phone Number: ( ) Employer(s) Name/Company:

Employer(s) Address:

Employer(s) Address:

Employer(s) ID Number: Work Phone Number: ( )

Employer(s) ID Number: Work Phone Number: ( CHILD/CHILDREN INFORMATION MIDDLE INITIAL DATE OF BIRTH SOCIAL SECURITY NUMBER )

LAST 1. 2. 3. 4. 5.

FIRST

(If more space is needed, attach an additional sheet.) *If obligor is not a US citizen, so indicate and provide the obligor's alien registration number, passport number and home country's social security or national health number.

Form Approved by Conference of Chief Circuit Judges

Exhibit 1

Revised 4/28/06

Case No.

Instructions for Affidavit & Application To Sue or Defend as an Indigent Person
If you claim you are not financially able to pay filing fees and costs, you may apply to the Court for waiver of those charges as an indigent person. To seek waiver of those fees, you must complete and submit the form "Affidavit & Application to Sue or Defend as an Indigent Person." Please submit the completed form as soon as possible so that the Judge can rule on your request, and you can provide further information if required. You must PRINT all of the information required on the form and sign your signature affirming under penalty of perjury that the information you have given is truthful. Complete all parts of the form. The Judge will review your completed application and either grant or deny it or require additional information. If you are being sued and the Court denies the application, you will have to pay the filing fees before the answer date or extension. If you do not, a default Judgment may be entered against you.
In order to qualify as indigent, the Court uses income guidelines based on those established by U.S. Department of Health and Human Services:

2008 GUIDELINES ­ INDIGENT PARTY
(125% of Health & Human Services Poverty Level)

SIZE OF FAMILY 1 2 3 4 5 6 7 8

YEARLY $13,000 $17,500 $22,000 $26,000 $31,000 $35,000 $40,000 $44,400

MONTHLY $1,083 $1,458 $1,833 $2,208 $2,583 $2,958 $3,333 $3,708

For family units with more than 8 members, add $4,350 yearly or $363 monthly for each additional person.

IN THE CIRCUIT COURT FOR THE THIRD JUDICIAL CIRCUIT MADISON COUNTY, ILLINOIS _________________________________________, Plaintiff vs. _________________________________________, Defendant

Case No. __________________

AFFIDAVIT AND APPLICATION TO SUE OR DEFEND AS AN INDIGENT PERSON The undersigned as affiant, under penalty of perjury as provided in Section 735 ILCS 5/1-109, certifies that the statements in this instrument are true and correct, or made on information and belief and believed to be true: 1.) I am familiar with the facts stated herein and this Application to Sue or Defend as an Indigent Person is brought for: myself as Applicant on behalf of a minor or a disabled adult, ________________________________. 2.) The applicant is named as a defendant in a pending action or intends to file a lawsuit. 3.) The applicant receives assistance from the following benefit programs: SSI, AABD, TANF, Food Stamps, General Assistance, State Transitional Assistance, State Children & Family Assistance. (Circle all benefits received.) 4.) The applicant's household income is 125% or less of the current poverty level as established by the United States Department of Health and Human Services. (Clerk will provide current chart to make this determination.) (You must also provide the following information to confirm your eligibility.) Number of persons in applicant's household ________ Household income: $_____________ monthly. The applicant's household income includes Social Security Disability Payments. Unemployment compensation benefits. 5.) The applicant is unable to proceed in an action without payment of fees, costs, and charges and the applicant's payment of those fees, costs, and charges would result in substantial hardship to the applicant or the applicant's family. 6.) Applicant is: unemployed, or $ ____________ monthly. 7.) Applicant is monthly. married, or employed, and the applicant's current income is

unmarried. The applicant's spouse's current income is $____________

8.) Applicant is

receiving

paying child support in the amount of $___________ monthly.

Case No

9.) The applicant has the following assets: money in banks, credit unions and savings & loans, in the amount of $__________ real estate with equity of $_____________ located at ____________________________ automobiles with equity of $ _____________ (Equity is the value of the property minus any mortgage or debt.) other financial assets, including retirement accounts, of $___________ other assets____________________________________ in the amount of $___________ 10.) The applicant's total monthly living expenses are $______________ as follows: (Do not include payments for debts or child support.) Rent or mortgage payment: ___________ Food: ___________ Clothing: _________ Car payment: _________ Car insurance:_________ Gasoline & maintenance: _________ Utilities: _____________ Telephone: ____________ Child care: _____________ Medical, hospital & prescription: _______________ Insurance: _______________ Other: _____________________________________________________________________ 11.) The affiant, in good faith, believes that the applicant has a meritorious claim or defense. Wherefore, the Affiant seeks permission of this Court for the Applicant to sue or defend as an indigent person.

Affiant

ORDER Having reviewed the Application to Sue or Defend as an Indigent Person, the Court now enters its Order: Application ALLOWED. The applicant is allowed to sue or defend as a poor person without payment of fees, costs or charges. Assessment against any other party is reserved pending outcome. Application DENIED for the following reason(s): Applicant is not indigent. Other: ________________________________________________ ________________________________. Applicant granted _____ days to pay filing fees. Application is INCOMPLETE. Default Judgment may be entered if application is not completed by the answer date or extension. Applicant granted _____ day extension to submit completed application. RULING RESERVED. Applicant MUST submit most recent Federal income tax return along with year-to-date paycheck stub or statement within _____ days. Failure to do so may result in entry of Default Judgment.

__________________________ Date

__________________________________________ Presiding Judge

Clerk to mail copies of this Application and Order to all parties of record. Rev. 3-2-04

Case No