Family Support Affidavit {CCDR N108}

Print Form Clear Form Family Support Affidavit (Rev. 12/12/14) CCDR N108 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION In Re the q Marriage q Civil Union q Custody q Support of: _____________________________________________________ Petitioner and _____________________________________________________ Respondent Calendar: ______________________________ No. ___________________________________ FAMILY SUPPORT AFFIDAVIT This completed form must be attached to any judgment, decree or order of court which contains an initial or modification of an order for the payment of child support and/or maintenance. Both parties may use one form or they may complete separate forms. If either party is not present, both Part I and Part II must be completed by the party who is present to the best of her/ his information and belief. PART I. To be completed by Custodial Parent Full Name _____________________________________________________ Date of Birth _______________________ Residential Address__________________________________________________________________________________ City _____________________________ County _______________________ State ______ Zip Code _____________ Mailing Address (if different) __________________________________________________________________________ Social Security No.____________________ Home phone (_____) ____________ Work phone (_____) _____________ Employer _________________________________________________________________________________________ Address __________________________________________________________________________________________ City _____________________________ County _______________________ State ______ Zip Code _____________ Driver's License No. (Illinois) ________________________ Driver's License No. (other state) _______________________ Child(ren) covered by Order For Support: Full Name(s) Sex Date of Birth Social Security No. ___________________________________________________________________________________________________________ _________________________________________________________________________________________________ Child(ren) receiving Public Assistance? (Yes or No): ________________ If yes, give case number: ______________________________________ Title IV-D Program (Yes or No): _______________________________ If yes, give case number: ______________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 2 Family Support Affidavit PART II. To be completed by Non-Custodial Parent (Rev. 12/12/14) CCDR N108 B Full Name _____________________________________________________ Date of Birth _______________________ Residential Address__________________________________________________________________________________ City _____________________________ County _______________________ State ______ Zip Code _____________ Mailing Address (if different) __________________________________________________________________________ Social Security No.________________ Home phone (_____) ____________ Work phone (_____) __________________ Employer _______________________________________________________ Telephone (_____) __________________ Address __________________________________________________________________________________________ City _____________________________ County _______________________ State ______ Zip Code _____________ Occupation _______________________________________________________________________________________ Height:__________ Weight: __________ Eyes: __________ Complexion:____________________________________ Race: ___________________ Birthplace (City, State) ______________________________________________________ Driver's License No. (Illinois) _______________________ Driver's License No. (other state) ________________________ Father's Name (last, first) _____________________________________________________________________________ Military Service? ___________________________ If yes, which Branch? __________________ Retired? ____________ *A party shall report to the Clerk of the Circuit Court of Cook County changes information required to be disclosed pursuant to *750 ILCS 5/505.3 within five (5) business days of the change. CERTIFICATION Under penalties provided by law pursuant to 735 ILCS 5/1-109 of the Illinois Code of Civil Procedure, the undersigned certifies that he/she knows the statements set forth in this document are true and correct, except as to matters therein specifically stated to be on information and belief and as to those matters the undersigned certifies that he/she believes them to be true. __________________________________ ___________ Custodial Parent Date * * * ______________________________ Non-Custodial Parent * * ______________ Date _______________________________________________ Attorney for Custodial Parent ______________________________________________ Attorney for Non-Custodial Parent Atty. No.: _____________________ Atty. Name: _________________________________________ Atty. for: ____________________________________________ Address: ____________________________________________ City/State/Zip: _______________________________________ Telephone: __________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 2