Free STATE OF ILLINOIS - Illinois

STATE OF ILLINOIS COUNTY

) IN THE CIRCUIT COURT OF THE FOURTEENTH ) JUDICIAL CIRCUIT _________ COUNTY, ILLINOIS ) ) ) ) ) ) NO. ) ) Pursuant to Local Rule this ) document to be filed under seal.

IN RE THE MARRIAGE OF:

Petitioner, and

Respondent.

CONFIDENTIAL DISCLOSURE STATEMENT OF PETITIONER/RESPONDENT HUSBAND Name: ______________________ Address: ____________________ ____________________________ Soc. Sec. # __________________ Date of Birth:_________Age:____ Employer:____________________ Employer Address ______________ ______________________________ Occupation:_____________________ WIFE Name: _____________________ Address:_____________________ ___________________________ Soc Sec.#______________________ Date of Birth:_________Age:_______ Employer:______________________ Employer Address________________ _______________________________ Occupation:_____________________

CHILDREN OF THIS MARRIAGE/RELATIONSHIP NAME _______________ _______________ _______________ Date of Birth __________ __________ __________ Age ___ ___ ___ With Whom Residing _________________ _________________ _________________

NAME ___________ ___________

OTHER CHILDREN Date of Birth Age With Whom Residing __________ ___ __________________ __________ ___ __________________

Other Case Number ________________ ________________

KNOWN MEDICAL CONDITIONS OF PARTIES/ CHILDREN ________________________________________________________________________ ________________________________________________________________________

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I, the undersigned, declare and certify pursuant to 735 ILCS 5/2-1009, under penalties of perjury, that the foregoing, including any attachments, is a true and correct to the best of my knowledge, information and belief, and that I executed this on the ______________ day of _______________________________, 20_______.

_____________________________ SUBSCRIBED AND SWORN to before me this ________________ day of ___________________, 20_________.

_____________________________ NOTARY PUBLIC BY: _____________________________ Attorney Attorney Name Attorney Address Attorney Phone Number:

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