Declaration Under UCCJEA {171-145}

IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS _____________________________________________ ) Petitioner ) vs. ) ) ) _____________________________________________ ) Respondent Case No. ________________________ Declaration Under Uniform Child-Custody Jurisdiction And Enforcement Act (UCCJEA) Pursuant to 750 ILCS 36/209 I, 1. _____________________________________________________ , certify that the following statements are true: (Your full name) _____________________________________________________ and I are the parents of: (Other parent's full name) ____________________________________________________________ (Child's full name) date of birth: _____________ (mmddyyyy) ____________________________________________________________ (Child's full name) date of birth: _____________ (mmddyyyy) ____________________________________________________________ (Child's full name) date of birth: _____________ (mmddyyyy) ____________________________________________________________ (Child's full name) date of birth: _____________ (mmddyyyy) ____________________________________________________________ (Child's full name) date of birth: _____________ (mmddyyyy) ____________________________________________________________ (Child's full name) date of birth: _____________ (mmddyyyy) (Attach additional pages as needed) 2. The child(ren) have lived at the following addresses in the past five years: _________ to _________ (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) (mmyyyy) ___________________________________________ Address _______________________ (With whom?) _________ to _________ _________ to _________ _________ to _________ _________ to _________ _________ to _________ ___________________________________________ Address _______________________ (With whom?) ___________________________________________ Address _______________________ (With whom?) ___________________________________________ Address _______________________ (With whom?) ___________________________________________ Address _______________________ (With whom?) ___________________________________________ Address _______________________ (With whom?) (Attach additional pages as needed) 3. If the child(ren) has/have lived with someone other than you at any time during the last 5 years, state that person's name and current address(es): _________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Page 1 of 2 171-145 (Rev. 06/13) American LegalNet, Inc. www.FormsWorkFlow.com 4. The child(ren) now live(s) with: me the other parent both of us other: _________________________________________________ (Describe the child(ren)'s living situation) Check the following statements that are true: 5. a. The child(ren) over the age of 6 months have lived in Illinois for at least the last 6 months. b. The child(ren) under the age of 6 months have lived in Illinois since birth. 6. a. On information and belief, there are no other legal proceedings or court orders involving the custody of, or visitation with my child(ren), and I have not participated in any other case(s) involving custody of, or visitation with my child(ren) in this, or any other state OR b. On information and belief, the only legal proceedings, court orders, or cases that I have participated in involving the custody of, or visitation with my child(ren), in this, or any other state, are those listed below: _________________________________________ Case Name _________________ County/State _______________________ Date of last court order _________________________________________ Case Name _________________ County/State _______________________ Date of last court order _________________________________________ Case Name _________________ County/State _______________________ Date of last court order 7. Other than the parties to this case, no other person claims to have rights of custody and/or visitation with the child(ren) except: ______________________________________________________________________________ . 8. I understand that I have a continuing duty to inform the court of any proceeding in this or any other state, that could affect the current proceedings. Certification Under penalties provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matter therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the same to be true. Date: _________________________________ ___________________________________________ Signature Page 2 of 2 171-145 (Rev. 06/13) American LegalNet, Inc. www.FormsWorkFlow.com