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Free Illinois Divorce with Minor Children Form - PDF Form Download

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Download and use this form in the State of Illinois if you want to file for a Divorce and you have Minor children.


illinois-forms-for-divorce-with-minor-children

Text version of this Form

———————– Page 1———————–

How to file for divorce in Illinois — Supplement A

Divorce with minor children

This supplement includes a forms guide as well as forms. The forms guide is for use only in
filling out the forms. For more information about what these forms mean or are used for,
consult the appropriate Self Help packet.

8Board of Trustees, Southern Illinois University
May 2003

———————– Page 2———————–

Forms that are included in this supplement:

Application to Sue As A Poor Person

Entry of Appearance, Waiver, and Consent

Entry of Appearance, Waiver, and Consent — Military

Petition for Dissolution of Marriage — children

Stipulation to Waiver of the Two Year Requirement

Notice of Hearing

Certificate of Mailing of Notice of Hearing

Judgment of Dissolution of Marriage — children

Certificate of Mailing of Judgment of Dissolution of Marriage

Notice of Withholding

Affidavit of Service of Notice To Withhold Income For Child Support

Child Support Information Sheet

Uniform Order of Support

Letter to State Disbursement Unit

Letter to Division of Child Support Enforcement

Letter to Employer of Party to Pay Support

———————– Page 3———————–

FORMS GUIDE

ALL FORMS:

At the top of each form is the “caption”. It is completed as follows:

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE (number of circuit) JUDIC IAL CIRCUIT

(name of county) COUNTY

IN RE THE MARRIAGE OF: )
)
(your name) )
)
Plaintiff, )
)
and ) No. (year) -D- (get from Clerk at the
) time you file)
(your spouse’s name) )
)
Defendant. )

Determine the number of the “Circuit” according to the chart on the next page. If your
county does not appear in the chart, call the Circuit Clerk in the county in which you will be
filing your case and ask for the number of the Circuit.

———————– Page 4———————–

Circuit Courts in Illinois

Cook County is its own judicial circuit. The rest of the counties in Illinois fall into one of 21
circuits.

First Circuit – The counties of Alexander, Pulaski, Massac, Pope, Johnson, Union, Jackson,
Williamson and Saline.

Second Circuit – The counties of Hardin, Gallatin, White, Hamilton, Franklin, Wabash, Edwards,
Wayne, Jefferson, Richland, Lawrence and Crawford.

Third Circuit – The counties of Madison and Bond.

Fourth Circuit – The counties of Clinton, Marion, Clay, Fayette, Effingham, Jasper, Montgomery,
Shelby and Christian.

Fifth Circuit – The counties of Vermilion, Edgar, Clark, Cumberland and Coles.

Sixth Circuit – The counties of Champaign, Douglas, Moultrie, Macon, DeWitt and Piatt.

Seventh Circuit – The counties of Sangamon, Macoupin, Morgan, Scott, Greene and Jersey.

Eighth Circuit – The counties of Adams, Schuyler, Mason, Cass, Brown, Pike, Calhoun and
Menard.

Ninth Circuit – The counties of Knox, Warren, Henderson, Hancock, McDonough andFulton.

Tenth Circuit – The counties of Peoria, Marshall, Putnam, Stark and Tazewell.

Eleventh Circuit – The counties of McLean, Livingston, Logan, Ford and Woodford.

Twelfth Circuit – The county of Will.

Thirteenth Circuit The counties of Bureau, LaSalle and Grundy.

Fourteenth Circuit – The counties of Rock Island, Mercer, Whiteside and Henry.

Fifteenth Circuit – The counties of JoDaviess, Stephenson, Carroll, Ogle and Lee.

Sixteenth Circuit – The counties of Kane, DeKalb and Kendall.

Seventeenth Circuit – The counties of Winnebago and Boone.

Eighteenth Circuit – The county of DuPage.

Nineteenth Circuit – The counties of Lake and McHenry.

Twentieth Circuit – The counties of Randolph, Monroe, St. Clair, Washington and Perry.

———————– Page 5———————–

Twenty-first Circuit – The counties of Iroquois and Kankakee.
FORM: Application to Sue as a Poor Person

Introduction: Your name

Paragraph 1: Your address, include street and city.

Paragraph 2: The amount and source of your income, for example, $339.00 per
month in AFDC, supplemented by Food Stamps.

Paragraph 3:. List other sources of income not listed in 2.

Paragraph 4: The amount of income you had in the last year.

Paragraph 5: Should be the same as 2, unless you expect your income to go up or
down, in which case you should list what you expect your income to
be.

Paragraph 6: List the names and birthdates of your children and/or others you
support financially.

Paragraph 7: First blank: total value of your possessions;

Second blank: year and make of your car; if you do not have a car,
simply put “none”;

Third blank: value of your car;

Sign your name on both blank lines above where it says “Plaintiff” and print your name
below each signature.

FORM: Petition For Dissolution of Marriage (children)

Introduction: Your name

Paragraph 2: First blank: Your age.

Second blank: Your address (street and city).

Third blank: The county in which you live.

Paragraph 3: First blank: Your spouse’s name.

Second blank: Your spouse’s age.

———————– Page 6———————–

Third blank: Your spouse’s address (street, city, and state)

Fourth and
Fifth blank: Check whether your spouse is or is not a resident
of the State of Illinois.

Paragraph 4: First and
Second blank: Day, month and year of your marriage.

Third blank: The city and state in which you got
married.

Fourth blank: The county in which your marriage was
registered.

Fifth blank: The state in which your marriage was
registered.

Paragraph 5: First and
Second blank: The month and year you and your spouse
separated. If not separated put n/a.

Third blank: The grounds for the divorce: (for example,
extreme and repeated mental cruelty; extreme and
repeated physical cruelty; irreconcilable
differences)

Paragraph 6: All blanks: list the full names and birthdates of all of the children you
had with your spouse;

Paragraph 7: If you are a male, change to indicate that your wife is not pregnant;

If you or your wife is pregnant: wait until after the child is born, if it is
a child of the marriage; If it is not a child of the marriage, change
Paragraph 7 to the following: “Wife is pregnant, but husband is not
the father.”

Paragraph 8: List the city and state for each address your child or children have
lived in the last five years.

Paragraph 9: List the name and current address of each person with whom the
children have lived in the last five years; this does not necessarily
mean that they were in the custody of someone else, but only refers to others with
whom your children resided.

Paragraph 10: First, Second,
and Third blank: put “none” if you are not currently involved
with any other custody proceedings with your

———————– Page 7———————–

children; if you have, put the case number, county
and state in which the other case is filed. Include
Orders of Protection which granted you temporary
custody of your children.

Paragraph 11: First, Second,
and Third blank: put “none” if there are no past custody cases
regarding your children; if there are, put the case
number, county and state in which the other case
was filed.

Paragraph 14: List your non-marital property. If there is not enough room, place
the remainder on an additional sheet and refer to it at the end of
Paragraph 14. (for example: “continued on a separate sheet.”)

Paragraph 15: List your marital property. If there is not enough room, place the
remainder on an additional sheet and refer to it at the end of
Paragraph 15. (For example: “continued on a separate sheet.”)

Paragraph 18: List the debts you and your spouse incurred while you were married.
If there is not enough room, place the remainder on an additional
sheet and refer to it at the end of Paragraph 18.(for example:
“continued on a separate sheet.”

Paragraph 19: Put your maiden or former name in the blank.

Paragraph I Enter any additional relief you want that is not
covered in A through H;

Sign your name on both blank lines above where it says “Plaintiff” and print your name
below each signature.

———————– Page 8———————–

FORM: Judgment of Dissolution of Marriage (children)

Introduction: First blank: Day of hearing.

Second blank: Month of hearing.

Third blank: Year of hearing.

Fourth blank: Your name.

Place a check in the box that corresponds with how your spouse was
served. CHECK ONLY ONE BOX. If you check the first box, the first
blank should be filled in with the county in which your spouse was
served and the second blank should be filled in with the state in
which that county is located.

Paragraph 2: First blank: Your age.

Second blank: Your address.

Third blank: Name of county in which you reside.

Paragraph 3: First blank: The age of your spouse.

Second blank: Your spouse’s address. If you don’t have an address
put “unknown”.

Third blank: The state where your spouse resides. If you don’t
know the state, put “unknown”.

Fourth and
Fifth blank: Check whether your spouse is or is not a resident
of Illinois.

Paragraph 4: First and
Second blank: The day, month, and year of your marriage.

Third blank: The county in which your marriage was
registered.

Fourth blank: The state in which your marriage was
registered.

Paragraph 5: Month and year on which you and your spouse separated.

Paragraph 6: Grounds on which you are getting a divorce.

———————– Page 9———————–

Paragraph 7: First blank: List the name and birthdate of each of the
children of the marriage.
Second blank: Put your complete address.

Paragraph 10: Check the appropriate box. If you check the first box: put the name
of the spouse’s employer and the amount of the spouse’s net
monthly salary.

Paragraph 11: List marital property as you did in your Petition.

Paragraph 12: List the non-marital property you have in your possession;

Paragraph 13: List the debts as you did in your Petition.

Paragraph 14: List your former name.

Paragraph B: List the visitation you want the court to give to your spouse. Be as specific
as you can.

Paragraph C: Check the appropriate box.

Box 1:

First blank: amount of child support to be paid.

Second blank: how often the amount of support is to be paid
(weekly, every 2 weeks, every month, etc.)

Box 2: Check this if no support is going to be paid.

Paragraph D: List the marital and non-marital property you want the court to award to you.
Paragraph E: List the debts you want your spouse to be responsible for.

Paragraph G: List your former name.

Paragraph I: List any relief you want the court to give you not requested in
Paragraphs A-H.

DO NOT FILL IN THE DATE OR THE SIGNATURE LINE FOR THE JUDGE.

FORM: Notice of Hearing (use only if you want to notify your spouse of the hearing)

First blank: Spouses name and address (include street, city, and state)

Second blank: Your name.

Third blank: Date of hearing.

———————– Page 10———————–

Fourth blank: Time of hearing. (be sure to put a.m. or p.m.)

Fifth blank: County in which your case is filed.

Sixth blank: City in which the courthouse is located.

Sign your name on the blank line next to where it says “Plaintiff” and print your name below
the signature.

FORM: Stipulation To Waiver Of The Two Year Requirement (use only if you have been
separated for less than 2
years but more than 6
months, you are using the
grounds of irreconcilable
differences, and your
spouse is willing to sign
this form)

Paragraph 1: Date of your marriage.

Paragraph 2: Month and year of your separation.

Sign your name on both blank lines above where it says “Plaintiff” and print your name
below each signature. Your spouse will sign on both blank lines above where it says
“Defendant” and will print his name below each signature.

FORM: Certificate of Mailing Of Judgment Of Dissolution Of Marriage

First blank: Your name.

Second blank: Name of city in which you mailed a copy of the Judgment to your
spouse.

Third blank: Date you mailed a copy of the Judgment to your spouse.

Sign your name on both blank lines above or next to where it says “Plaintiff” and print your
name below each signature.

FORM: Certificate of Mailing Of Notice Of Hearing (use only if you want to notify your
spouse of the hearing)

First blank: Your name.

———————– Page 11———————–

Second blank: Name of city in which you mailed a copy of the Notice Of Hearing to
your spouse.

Third blank: Date you mailed a copy of the Notice of Hearing to your spouse.

Sign your name on both blank lines above or next to where it says “Plaintiff” and print your
name below each signature.

Form: Notice to Withhold Income For Child Support (use only if asking for child support)

CAPTION:

Check one of the following:

Original Notice : if this is the first notice you have sent to the person who will be paying child
support.
Amended Notice : if you are changing the existing child support notice
Terminate Notice : if the child support order has been terminated by the court.

Employer/Withholder=s Fed. EIN No. :
the federal employer identification number of the
employer of the person paying support in this section.
To obtain this number, please contact the employer. If
you are not able to get the number, continue to
complete the form.

Employer/Withholder=s Name : the name of the employer

Employer/Withholder=s Address: the address of the employer

Employer/Obligor=s (Last, First, MI): the name of the person who will pay/or is paying the
support in this section.

Employer/Obligor=s Soc. Sec. No. : the social security number of the person who will
pay/or is paying the support in this section.

Employee Identification Number : the number assigned to the employee by the
employer, if the employer uses a numbering
system.

Custodial Parent (Last, First, MI): the name of the parent who is receiving the support in this
` section.

Custodial Parent’s Social Security Number: The Social Security number of the parent who is
receiving the support.

Child(ren) Name(s) : the names of all children receiving support in this section.

———————– Page 12———————–

Date of birth: the date of birth (next to the child=s name) of all children on whose
behalf
support is being paid.

ORDER INFORMATION:

1st Blank: the name of the judge who signed the most recent child support order

2nd Blank: the county that child support order is filed in

3rd Blank: the date that child support order was entered

4th Blank: the date on which the youngest child for which support is being paid turns
18.

5th Blank: Should be checked if children are to be enrolled in the insurance program of
the person who will pay/or is paying child support.

6th and 7th Blanks: The amount of child support and the frequency (weekly, monthly, bi-weekly)
that it is paid. For example $100 per month.

8th and 9th Blanks: The amount of past due child support and the frequency (weekly, bi-weekly,
monthly) that it is paid.
10th Blank: Should be checked (yes) if the person paying support is more than 12
weeks behind in paying child support.

11th & 12th Blanks: The amount of medical support and the frequency (weekly, monthly, bi-
weekly) that it is paid. For example $100 per month.

13th and 14th Blanks: Use these blanks for amounts paid that do not fit into either the
current support, past due support, or medical support categories.
Indicate the amount and the frequency (weekly, bi-weekly, monthly)
that it is paid.

15th and 16th Blanks: The total amount of support and the frequency (weekly, monthly, bi-
weekly) that it is paid..

17th through 20th Blanks: Using the total amount of support, calculate the amounts that an
employer would pay in either a weekly, monthly, semimonthly, or bi-
weekly pay cycle:

Example : If the total amount of support is $100 per month, then

the weekly pay period would be: $100 x 12 (12 months in a year) = 1200 ) 52 (52 weeks in a year)
= $23.07

the monthly pay period would be $100.00

———————– Page 13———————–

the semimonthly pay period (twice a month) would be $100 ) 2 = $50.00

and the biweekly pay period (every two weeks) would be:$23.07(weekly pay period) x 2 = $46.15

REMITTANCE INFORMATION :

1st Blank: the case number.

2nd Blank: the name of the individual or agency receiving the payment of support. If you are
receiving assistance for your children from the Illinois Department of Human
Services, put the Illinois Department of Human Services here.

3rd Blank: Put the name and address of the Circuit Clerk where your case is filed.

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS:

1st Blank: Check this box so that the employee/obligor will receive a copy.
2nd Blank: The name of the person paying support
3rd Blank: Leave blank, the employer will fill this blank out if the employee leaves his job
4th Blank: Leave blank, the employer will fill this blank out if the employee leaves his job
5th Blank: Leave blank, the employer will fill this blank out if the employee leaves his job

Put your name, address, and telephone number as the person who is preparing this Notice on the
last page.

FORM: Affidavit Of Service Of Notice To Withhold Income For Child Support

Introduction: Your name.

Paragraph 1: First blank: The employer to which you sent the Notice To
Withhold Income For Child Support.

Third blank: City from which you mailed the Notice to Withhold
Income For Child Support

Paragraph 2: The day, month, and year on which the Notice To Withhold was
received by the employer (will be on the green return receipt sent to
you by the Post Office).

Served by blank: Your name.

Sign your name on the blank line above where it says “Plaintiff” and print your name below
the signature.

FORM: Uniform Order For Support

———————– Page 14———————–

If you are getting a support order and you do not expect that there will be any disagreement about
it, you can complete the entire form as indicated in these instructions. If you expect that there will
be a disagreement, just complete numbers 1, 2, 3, and 5. The rest of the information can be
completed by the judge or the judge can tell you what he/she wants in each of the blanks after the
hearing.

In this document the person that will be paying the support is the Obligor and the person that will
be receiving the support is the Obligee. At the top of each page of the form is a space to insert the
case number of your case and each space should have the case number.

1. Check the “Initial Order” box if this is the first child support order in the case and the
“Modification” box if it is not.

2. Ignore the “Illinois Dept. of Public Aid” box.

3. Ignore the IDPA No.

4. Under the “The Court finds” section:
a. Check this box and in the blank write the amount of the obligor’s net income and the
period covered, for example, per month, per week, per 2 weeks, etc.
b. Check this box only is there is an arrearage of support (past due support) and in
the blank insert the amount. Usually you will leave this blank if there is a
disagreement about how much is owed. The judge can fill this blank after he/she
decides how much is owed.
c. You should not check this box. This is for special cases in which the support will be
ordered in a dollar amount plus a percentage of other income the obligor has, like
commission payments. This type of child support payment is not covered by the
instructions.

5. At the “It is ordered that” line write the name of the person who will be paying support.

6. Maintenance and unallocated support section: ignore.

7. Child Support section: check the box.
a. Payment amount blank: insert the total amount to be paid, including any arrearage
payment.
b. Current Child Support Payment: insert the amount of regular support.
c. Arrearage payment: insert the amount to be paid on any arrearage.
d. Payments begin: insert the date on which the payment are to begin.
e. Payment frequency: check the box that corresponds to how often the payments are
to be made.

8. Percentage Amount of Child Support section: ignore this section.

9. Payment arrangements section: check the box. Underneath this section you will normally
check the first and fourth paragraphs and these are the only sections the instructions
cover. If you want to use the second or third paragraph, you should seek the advice of an
attorney. In the fourth paragraph the first blank should be filled with the name of the county

———————– Page 15———————–

in which the order will be entered, the second blank is the address of the courthouse at
which the order was entered.

10. Delinquency section: check the box. In the first blank insert an amount that is 20% of the
normal child support amount, e.g. if the payment is $100.00 then the amount in the blank
would be $20.00.

11. Termination section: check the box. The first blank should contain the date on which the
youngest child will reach the age of 18 or the date on which the youngest child is expected
the graduate from high school, whichever is later.

12. Insurance section: check the box if the person paying support will also be providing medical
insurance through his/her job. This paragraph allows for several options for the payment of
the insurance premium. The instructions only cover the most common, which is when the
obligor gets insurance for the child. For that option you will check the obligor box in line
one and the first and second boxes in line two. Insert the name of the health insurance
provider and the policy number in the places indicated.

13. Additional conditions or findings section: check the box and check the last box which
concerns the child support date sheet. It is important that you check that last box because
it requires the circuit clerk to keep the information on the child support data sheet secret.
This is important because the information could be used by someone to commit the crime of
identity theft. The remaining two boxes in this section should be ignored. Those can be
completed by the judge if necessary.

———————– Page 16———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT

__________________ COUNTY

)
______________________ ) _____Application granted
) _____Application denied
Plaintiff, )
)
vs. ) No. _______
)
______________________ ) __________________, 20__
)
Defendant. ) ________________________
JUDGE

APPLICATION TO SUE AS A POOR PERSON

I, _____________________________________, on my own behalf, on oath state:

1. My current address is _________________________________________________

____________________________________________________________________.

2. My occupation, source of income, amount of public benefits is __________________

____________________________________________________________________.

3. My other sources of income or support are ________________________________.

4. My income for the preceding year was approximately ________________________.

5. The sources and amounts of income I expect to receive in the future are:

_____________________________________________________________________
.

———————– Page 17———————–

6. Person(s) who are dependent on me for support are: ________________________

_____________________________________________________________________

_____________________________________________________________________

.

7. I own no real estate. The total va lue of all my personal property does not exceed

$___________ in value and consists of clothing and furniture, and other household

items, including a 20____, ____________ motor vehicle, valued at $____________.

8. I filed no applications for leave to sue or defend as a poor person during the
preceding year, and none were filed on my behalf.

9. I am unable to pay the costs of commencing and prosecuting this action.

10. I have a meritorious claim.

WHEREFORE , Applicant prays the Court to permit her/him to commence and prosecute
this action as a poor person under 735 ILCS 5/5-105 of the Code of Civil Procedure.

___________________________________
Plaintiff

Under penalties as provided by law pursuant to Section 5/1-109 of the Code
of Civil Procedure, the undersigned certifies that the statements set forth in this instrument
are true and correct, except as to matters therein stated to be on information and belief and
as to such matters the undersigned certifies as aforesaid that he/she verily believes the
same to be true.

___________________________________
Plaintiff

———————– Page 18———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT

________________ COUNTY

IN RE THE MARRIAGE OF: )
)
______________________, )
)
Plaintiff, )
)
and ) No. ____-D-____
)
______________________, )
)
Defendant. )

ENTRY OF APPEARANCE
WAIVER AND CONSENT

I, ______________________, hereby enter my appearance in the above-entitled cause as

Defendant therein, and expressly waive the necessity of process of summons and consent that the

same proceedings may be had therein, 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 30

days prior to any return day designated by Plaintiff herein or as provided by law.

I further certify that I am aware that property owned by myself and Plaintiff may be classified

as marital or non-marital property, and I am aware that marital misconduct does not enter into a

judicial division of said property. I waive any right that I have to all of said property other than that

which will be awarded to me in accordance with the terms of the order for Judgment of Dissolution

of Marriage.

I further consent that immediate default may be taken and entered therein 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.

———————– Page 19———————–

SIGNATURE: ____________________________________

Dated ___________________________________, 20___.

STATE OF ________________)
)
County of _________________)

I, _______________________, a Notary Public in and for said County and State, do
hereby certify that _____________________________________, personally known to me to be
the same person whose name is subscribed to the foregoing waiver of summons, appeared before
me this day in person, and acknowledged that he signed said appearance as his free and
voluntary act, for the purpose therein set forth.

Given under my hand and Notarial Seal, _____________, 20___.

__________________________________
NOTARY PUBLIC

———————– Page 20———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT

________________ COUNTY

IN RE THE MARRIAGE OF: )
)
______________________, )
)
Plaintiff, )
)
and ) No. ____-D-____
)
______________________, )
)
Defendant. )

ENTRY OF APPEARANCE
WAIVER AND CONSENT – MILITARY

I _____________________________, hereby enter my appearance in the above-entitled

cause as the Defendant therein, and expressly waive the necessity of process of summons and

consent that 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 (30) days prior to any return day

designated by the Plaintiff herein, or as provided by law.

I 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 to me.

I further state that I am over the age of eighteen (18) years and hereby acknowledge and

expressly waive any and all rights that I may be entitled to under the Soldiers’ and Sailors’ Civil

Relief Act (50 U.S.C.A. App. Section 501) as amended.

I further certify that I am aware that property owned by myself and Plaintiff may be classified

as marital or non-marital property, and I am aware that marital misconduct does not

———————– Page 21———————–

enter into a judicial division of said property. I waive any right that I have to all of said property

other than that which will be awarded to me in accordance with the terms of the order for Judgment

of Dissolution of Marriage.

SIGNATURE: ____________________________________

Dated ___________________________________, 20___.

STATE OF __________)
)
County of ___________)

I, _______________________, a Notary Public in and for said County and State, do
hereby certify that _____________________________________, personally known to me to be
the same person whose name is subscribed to the foregoing waiver of summons, appeared before
me this day in person, and acknowledged that he signed said appearance as his free and
voluntary act, for the purpose therein set forth.

Given under my hand and Notarial Seal, _____________, 20___.

______________________________________
NOTARY PUBLIC

———————– Page 22———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ________ JUDICIAL CIRCUIT

_____________ COUNTY

IN RE THE MARRIAGE OF: )
)
_____________________, )
)
Plaintiff, )
)
and ) No. ____-D-____
)
_____________________, )
)
Defendant. )

PETITION FOR DISSOLUTION OF MARRIAGE – CHILDREN

I, ________________________________, without the assistance of an attorney, ask this Court for

a Dissolution of Marriage. In support of my Petition, I state the following items are true:

1. This Court has jurisdiction over the subject matter, myself, and my spouse.

2. I am ____ years old. I reside at ____________________________________. I live in

____________ County. I have been a resident of the State of Illinois for ______ years. My

occupation is ______________________________.

3. My spouse’s name is _______________________. He/she is _____ years old. His/her

address is___________________________________; and he/she has been a resident of Illinois

for _____ years. His/her occupation is _________________________. My spouse is not currently

in military service with any of branches of the Armed Forces of the United States.

4. There are no other petitions for dissolution of marriage pending in any other county or

state.

———————– Page 23———————–

5. My spouse and I were lawfully married on __________________, 20 ___ at

____________________________________________, and the marriage was registered at

_____________________ County, in the State of ________________________________.

6. My spouse and I have lived separate and apart continuously since ____________

________________, 20 ___ and the reason I want a divorce is: _______________________

__________________________________________________________________________ as

defined by the Illinois Marriage and Dissolution of Marriage Act.

7. That the following children were born to or adopted by my spouse and me:

_________________________________________, date of birth: _____/_____/____;

_________________________________________, date of birth _____/_____/_____;

_________________________________________, date of birth _____/_____/_____;

_________________________________________, date of birth: _____/_____/____;

_________________________________________, date of birth _____/_____/_____;

_________________________________________, date of birth _____/_____/_____.

All of our child/ren reside with me and they have lived in Illinois for at least the last 6 months.

8. I am not pregnant.

9. Our child/ren have lived in the following places the last five years:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________.

10. Our child/ren have lived with the following people in the last five years:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________.

———————– Page 24———————–

11. As far as I know, there are no custody cases involving our children pending in a court

of this or any other state, except ______________ v. _______________, which is currently

pending in ______________________, County, State of ____________________.

12. As far as I know, there are no past custody cases involving the custody of our children

in a court of this or any other state except:________________ v. _______________, which was in

__________________________, County, State of ___________________.

13. No other person other than me and my spouse has physical custody of our child/ren or

claims to have a right to custody or visitation with the child/ren.

14. Our child/ren are in my custody; I should have the temporary and permanent care,

custody, control, and education of our child/ren; and it is in the best interests of the child/ren that

care, custody, control, and education be awarded to me.

15. I have in my possession the following items of non-marital property (property I got prior

to our marriage, by inheritance, or by gift). My spouse did not help pay for this property, and

he/she has no legal right to any part of it:_______________________________________

__________________________________________________________________________

__________________________________________________________________________.

16. Our martial property (property we got after our marriage and not by inheritance or by

gift) includes, but is not limited to, the following: __________________________________

___________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________. I helped

pay for our marital property.

17. I do not know if my spouse has obtained any marital property or debts since our

separation.

———————– Page 25———————–

18. Our martial debts (debts we got after our marriage) include, but are not limited to, the

following: ________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________.

19. My former/maiden name was: ______________________________________.

WHEREFORE, I request:

A. A Judgment of Dissolution of Marriage.

B. That the Court award to me the temporary and permanent care, custody, control, and

education of our child/ren and determine what kind of visitation my spouse will get.

C. That the Court award to me all of the marital and non-marital property now in my

possession.

D. That the Court award to my spouse all of the marital and non-marital property now in

his/her possession.

E. That the Court order my spouse to take responsibility and pay for all legal debts,

liabilities and obligations we obtained since we got married.

F. That the Court order my spouse to pay me child support.

G. That neither party be awarded maintenance.

H. That I be allowed to use my maiden/former name.

I. That _______________________________________________________________

___________________________________________________________________________.

___________________________, Plaintiff

———————– Page 26———————–

Under penalties as provided by law pursuant to Section 5/1- 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 matters therein stated to be on information and belief and as to such matters

the undersigned certifies as aforesaid that she/he verily believes the same to be true.

____________________________, Plaintiff

———————– Page 27———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE _____________ JUDICIAL CIRCUIT

_________________ COUNTY

IN RE THE MARRIAGE OF: )
)
_________________________, )
)
Plaintiff, )
)
and ) No. ____-D-_____
)
__________________________, )
)
Defendant. )

STIPULATION TO WAIVER OF TWO-YEAR REQUIREMENT

Plaintiff and Defendant hereby agree that the following is true:

1. That we are Husband and Wife, and were married on ____________________,

20____.

2. We have been separated since on or about _______________, 20____; a continuous

period not less than six (6) months.

3. There has been an permanent breakdown of our marriage without hope of reconciliation

and we want to get a divorce without proving that one of us is at fault, and we waive the normal two-

year separation requirement.

4. We both understand the legal effect of this waiver and no one is forcing us to sign it and

we want to be held to this agreement.

______________________________ ________________________________
Plaintiff Defendant

Under penalties as provided by law pursuant to Section 5/1- 109 of the Code of Civil

Procedure, the undersigned certify that the statements set forth in this instrument are true and

———————– Page 28———————–

correct, except as to matters therein stated to be on information and belief and as to such matters

the undersigned certify as aforesaid that she/he verily believes the same to be true.

_________________________________ ________________________________
Plaintiff Defendant

———————– Page 29———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ______________ JUDICIAL CIRCUIT

__________________ COUNTY

IN RE THE MARRIAGE OF: )
)
_________________________, )
)
Plaintiff, )
)
vs. ) No. ____-D-____
)
_________________________, )
)
Defendant. )

NOTICE OF HEARING

To: ____________________________________

____________________________________

____________________________________

YOU ARE HEREBY NOTIFIED that a hearing on the Petition for Dissolution of

Marriage filed by __________________ is set for _________________, at _________ ___.m. at

the ______________ County Courthouse, _____________________, Illinois. You may be present

if you wish.

____________________________Plaintiff

———————– Page 30———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ____________ JUDICIAL CIRCUIT

____________________ COUNTY

IN RE THE MARRIAGE OF: )
)
__________________________, )
)
Plaintiff, )
)
vs. ) No. ____-D-____
)
__________________________, )
)
Defendant. )

CERTIFICATE OF MAILING OF NOTICE OF HEARING

I, _______________________, hereby certify that I mailed a copy of the Notice of Hearing

to the Defendant at his/her last known address by depositing the same in the United States mail at

_______________________, Illinois, postage fully prepaid on ________________, 20____.

______________________, Plaintiff

Under penalties as provided by law pursuant to Section 5/1- 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 matters therein stated to be on information and belief and as to such matters
the undersigned certifies as aforesaid that she/he verily believes the same to be true.

______________________, Plaintiff

———————– Page 31———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ________________ JUDICIAL CIRCUIT

___________________ COUNTY

IN RE: THE MARRIAGE OF: )
)
_________________________, )
Plaintiff, )
and )
) No. ____-D-____
_________________________, )
Defendant. )

JUDGMENT OF DISSOLUTION OF MARRIAGE – CHILDREN

This cause having come up for hearing on the ______ day of _______________, 20 __,

on the Petition for Dissolution of Marriage filed by_________________________, and:

( ) it appearing that Defendant was personally served with summons in ________________

County, __________________, and was defaulted for failure to appear or respond;

( ) it appearing that Defendant has filed an Entry of Appearance and consented, in sincerity

and without fraud or collusion to an immediate hearing;

( ) that on due inquiry, Defendant could not be found, and service was obtained in

accordance with 750 ILCS 5/2-206 and 2-207;

and the Petition herein taken as confessed by said Defendant, the Court having heard the

evidence and being fully advised in the premises does find:

1. That this Court has jurisdiction of the subject matter herein and the parties hereto.

2. That Plaintiff is ____ years old. She/He currently lives in________________, Illinois, in

________________ County, and has lived in Illinois for at least 90 days prior to the filing of his/her

Petition.

———————– Page 32———————–

3. That Defendant is ____ years old. His/Her last known address is

_____________________________, State of ______________________and is ___ is not ___ a

resident of Illinois. Defendant is not currently in military service with any of the Armed Forces of the

United States.

4 . That the parties were lawfully married on _____________, 20 ___ and that said

marriage was registered in ___________________County, __________________.

5. That the parties have been separated since _________________________, 20 ____.

6. That the grounds of have

been proven within the meaning of the Illinois Marriage and Dissolution of Marriage Act.

7. That all the children who have been born to the parties as a result of their marital

relationship are as follows:

, and that the home state of the minor child/ren is

the State of Illinois.

8. That Plaintiff is not now pregnant.

9. That Plaintiff is a fit and proper person to have the care, custody, control, and education

of the minor child/ren and that, considering the surroundings, circumstances, and adjustment to

home, school, and community of each child and the financial circumstances, character, fitness,

mental, and physical health of the parents and their ability to contribute to the

support of said child/ren, the best interests of the child/ren will be served if given into the custody

of Plaintiff.

10. ( ) That Defendant is employed at ________________________ earning

$________ net per month and is amply able to furnish support for the minor

child/ren of the parties, in accord with his/her/their needs;

( ) That Defendant is either unemployed or his/her employment status and income

are unknown.

———————– Page 33———————–

11. That since the marriage of the parties, the parties acquired marital property, including:

__________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________; that

Plaintiff has contributed to the acquisition and preservation of the marital property through her/her

own efforts and frugalities.

12. That Plaintiff has in her/his possession the following items of non-marital property:

.

13. That debts and obligations were incurred by the parties, as a result of the marriage

relation, including: ____________________________________________________

______________________________________________________________________________

________________________________________________________________________.

14. That Plaintiff’s former name was _______________________________________.

IT IS THEREFORE ORDERED, ADJUDGED AND DECREED BY THE COURT AS FOLLOWS:

A. That the bonds of matrimony presently existing between Plaintiff and Defendant be and

the same are hereby dissolved and the parties are granted a Judgment of Dissolution of Marriage.

B. That Plaintiff shall have and she/he is hereby awarded the sole care, custody, control,

and education of the child/ren of the parties, subject to the right of Defendant to visit with said

child/ren as follows:___________________________________________________

___________________________________________________________________________

___________________________________________________________________________.

C.

( ) That the Court shall enter a Uniform Order of Support in the amount of ___________

per ___________.

———————– Page 34———————–

( ) That the question of child support shall be reserved for the future consideration of the

Court.

D. That Plaintiff shall have as her sole and exclusive property free of homestead, dower,

or any right of Defendant all property presently in her/his possession,

including:______________________________________________________________________

_________________________________________________________________________.

E. That Defendant shall assume full responsibility for all the following legal debts and

obligations incurred by the parties, or either of them, as a result of this marriage relation, and hold

Plaintiff free and harmless therefrom including: ___________________________________

______________________________________________________________________________

_________________________________________________________________________.

F. That each of the parties is forever barred from claiming maintenance from the other,

having waived the right thereto, and from any and all other rights, claims, title or interest

whatsoever against the other party or in or to the property of the other, whether the property be

real, personal or mixed or whether it be now owned or hereafter acquired, especially rights of

dower, homestead or other rights of inheritance.

G. That Plaintiff is permitted to resume her former name of ____________________.

H. That this Court shall retain jurisdiction of this cause until the terms of this Judgment

have been fully complied with in all respects.

I. __________________________________________________________________

__________________________________________________________________________

DATE: ____________________ ENTER:_____________________________
JUDGE

———————– Page 35———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ____________ JUDICIAL CIRCUIT

____________________ COUNTY

IN RE THE MARRIAGE OF: )
)
__________________________, )
)
Plaintiff, )
)
vs. ) No. ____-D-____
)
__________________________, )
)
Defendant. )

CERTIFICATE OF MAILING OF JUDGMENT OF DISSOLUTION OF MARRIAGE

I, _______________________, hereby certify that I mailed a copy of the Judgment of

Dissolution of Marriage to the Defendant at his/her last known address by depositing the same in

the United States mail at _______________________, Illinois, postage fully prepaid on

________________, 20____.

______________________, Plaintiff

Under penalties as provided by law pursuant to Section 5/1- 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 matters therein stated to be on information and belief and as to such matters
the undersigned certifies as aforesaid that she/he verily believes the same to be true.

______________________, Plaintiff

———————– Page 36———————–

NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

State of Illinois

County of :____________________ ( ) Original Notice
Case Number:_________________ ( ) Amended Notice
Date: ________________________ ( ) Terminate Notice

______________________________ ____________________________
Employer/Withholder’s Fed. EIN No. Employee/Obligor’s (Last, First, MI)

______________________________ ____________________________
Employer/Withholder’s Name Employee/Obligor’s Soc. Sec. No.

______________________________ ____________________________
Employer/Withholder’s Address Court Case Number

______________________________ ____________________________
AND ANY SUBSEQUENT EMPLOYER Custodial Parent’s (Last, First, MI)

____________________________
Custodial Parent’s Social Security #

Child(ren)=s name (s): date of birth: Social Security Number:

___________________ _______________ __________________________

___________________ _______________ ________________ __________

___________________ _______________ ________________ __________

ORDER INFORMATION : This is a Notice to Withhold Income for Child Support based

upon an order for support entered by the Honorable ___________________________,

———————– Page 37———————–

Circuit Court of _________________ County, IL on _____________________, 20 ___.

By law, you are required to deduct these amounts from the above -named employee or

obligor=s income until ________ , 20___ even if the 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 obligator’s employment.

$______ per _____ in current support

$______ per _____ in past due support totaling $______

Arrears 12 weeks or greater? (__)yes (__) no

$______ per _____ in medical support

$______ per _____ in ______

for a total of $______ per ______ to be forwarded to the payee below.

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 semimonthly pay period (twice a month).

$_____ per monthly pay period. $______ per biweekly pay period (every two weeks).

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 Notice. Send payment within 7 working days of the
paydate/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 FCCPA % of the employee/obligor’s

———————– Page 38———————–

aggregate disposable weekly earnings. For the purpose of the limitation on
withholding, the following information is needed (see #9 below):

When remitting payment, provide the paydate that you withheld support and the case
number: ________________.

Make it payable to :______________________________________________________

Send check to :_________________________________________________________

ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS

(__) If checked, you are required to provide a copy of this form to your employee.

1. Priority: Withholding under this 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 person/agency listed below.

2. 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/obligator.

3. 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 on which the income is deposited directly in his/her
account.

4. Employee/Obligor with Multiple Support Withholdings:
If you receive more than one 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 Notices’ current support
withholdings before you withhold for any arrearages, to the greatest extent

———————– Page 39———————–

possible under the withholding limit. You should immediately contact the last
agency that sent you a notice to find the allocation law of the state of the
employee’s principal place of employment.

5. Termination Notification: You must promptly notify the payee when the
employee/obligor is no longer working for you.
Please provide the information requested on
the following page and return a copy of this
order/notice to the person/agency.

Information Requested:

EMPLOYEE’S/OBLIGOR’S NAME:________________________________________

DATE OF SEPARATION/TERMINATION OF EMPLOYMENT:___________________

LAST KNOWN HOME ADDRESS:_________________________________________

_____________________________________________________________________

_____________________________________________________________________

NEW EMPLOYER’S NAME AND ADDRESS:_________________________________

_____________________________________________________________________

Return Copy to: _______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

6. Lump Sum Payments: You may 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.

7. Liability: If you fail to withhold income as the 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 fail to withhold
or pay over and fines up to $100.00 per day for each day after the

———————– Page 40———————–

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.

8. 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 a child support
withholding.

9. Withholding Limits: You may not withhold more than the lesser of ; 1)the
amounts allowed by the Federal Consumer Credit
Protection Act (15 U.S.C.’1673 (b) ); or 2) the amounts
allowed by the State of the employee/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 second family; and/or 2) %5 if arrears
are more than 12 weeks old (see page 1).

10. 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.

Name and address of person preparing this Notice:

_______________________________________

———————– Page 41———————–

_______________________________________

———————– Page 42———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE _______________ JUDICIAL CIRCUIT

________________ COUNTY

IN RE THE MARRIAGE OF: )
_________________________, )
)
Plaintiff, )
)
vs. ) No. ____-D-____
)
_________________________, )
)
Defendant. )

AFFIDAVIT OF SERVICE OF
NOTICE TO WITHHOLD INCOME FOR CHILD SUPPORT

I, _________________________ state the following:

1. That a copy of the Notice To Withhold Income For Child Support entered in the

has been delivered to:_______________________________________________

by mailing it by certified mail, return receipt requested, with postage prepaid at
________________________, Illinois.

2. That service was made on _______________________ by certified mailing.

Served by: _________________________________

This form must be filed with the Clerk of the Court fo llowing service of a
Notice To Withhold Income For Child Support. Attach the green receipt card to this
form and file with the Clerk of the Court.

Under penalties as provided by law pursuant to Section 5/1-109 of the Illinois Code
of Civil Procedure, the undersigned certifies that the statements set forth in this instrument
are true and correct.

———————– Page 43———————–

_________________,Plaintiff

———————– Page 44———————–

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ____________________ JUDICIAL CIRCUIT

______________________ COUNTY

__________________________________, Plaintiff )
)
v. ) No. ___________________
)
________________________________, Defendant )
)

CHILD SUPPORT INFORMATION

Plaintiff Information Defendant Information

_____________________________________
__________________________________________
Last Name First MI Last Name First MI

Residental Address: Residential Address:

_______________________________________
__________________________________________

City: __________________________________ City:
______________________________________

State: ________________Zip: ______________ State: ___________________ Zip: _____________

Date of Birth: ___________________________ Date of Birth: ______________________________

Soc. Sec. No.: __________________________ Soc. Sec. No.:
______________________________

Driver’s License No.: _____________________ Driver’s License No.:
_________________________

Home Phone ( ) _____________________ Home Phone ( ) _________________________

Employer Name and Address: Employer Name and Address:

_______________________________________
__________________________________________

_______________________________________
__________________________________________

Employer(s) ID Number: ___________________ Employer(s) ID Number:
_______________________

Work Phone ( ) _______________________ Work Phone ( ) __________________________

———————– Page 45———————–

Child/Children Information:

Last Name First Name MI Date of Birth Social Security Number

1.
___________________________________________________________________________________

2.
___________________________________________________________________________________

3.
___________________________________________________________________________________

4.
___________________________________________________________________________________

5.
___________________________________________________________________________________

———————– Page 46———————–

IN THE CIRCUIT COURT OF THE __________________ JUDICIAL CIRCUIT

______________________________ COUNTY, ILLINOIS

UNIFORM ORDER FOR SUPPORT

[ ] Initial Order
[ ] Modification
_______________________ )
Petitioner/Plaintiff, ) Court Case No. _____________
)
vs. ) Illinois Dept. of Public Aid is, or has been,
) granted leave to intervene.
_______________________ )
Respondent/Defendant, ) IDPA 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 on the date of this order is $_________________________.
[ ] b) The amount of arrearage on 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 or payment, or
amount.

It is ordered that _____________________________, Obligor, is to provide:
[ ] MAINTENANCE OR [ ] UNALLOCATED SUPPORT

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

Payment Amount:_____________ Payment Frequency:
[ ] every week
Current Child Support Payment: $__________ [ ] every other week
[ ] monthly
Arrearage Payment: $__________ [ ] twice each month on ________ & ________ (date)

———————– Page 47———————–

[ ] every year
Payments Begin: ____________________(date) [ ] other _________________
[ ] PERCENTAGE AMOUNT OF CHILD SUPPORT
(Complete this Section only if Finding c) is checked above.)

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.

[ ] 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 listed in this Order. PAYABLE to the STATE DISBURSEMENT UNIT and sent to State
Disbursement Unit, 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 the Court.

OR
[ ] 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 PAYABLE 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.

OR
[ ] State law does not require payment to the State Disbursement Unit, and the parties have not
entered into a written agreement as provided above. PAYABLE to
____________________________ and sent to THE CLERK OF THE CIRCUIT COURT
at_______________________________________. Payments must include CASE NUMBER and
COUNTY of the Court issuing this Order.

OR
[ ] 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 ______________________________
County at _____________________________________and not to the State Disbursement Unit.

[ ] DELINQUENCY

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),

———————– Page 48———————–

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% per annum. Interest due and owing as a result of unpaid support will be set forth
under “Additional Conditions or Findings” in this Order or in a separate order.
[ ] 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, whicheve r comes later.) This termination date does
not apply to any arrearage that may remain unpaid on that date. The child/ren 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
dependant benefits/coverage are as follows:

Name of Health Insurance Provider(s): Policy No.(s):

_______________________________________________________________________________
It is further ordered that:

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 Illinois Department of Public Aid, in
writing, within 7 days:
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

———————– Page 49———————–

[ ] Child Support payment amount deviates from the amount required by statutory minimum
guidelines. The amount that would have been required under the guidelines is $***.

Reasons for deviation:
_____________________________________________________________________.

[ ] Other:

______________________________________________________________________________________

[ ] The “Child Support Data Sheet” filed herein, is a part of this Order. It is ordered that the
circuit clerk impound the “Child Support Data Sheet” until further order of this Court.

DATE: ________________________ ENTER: ____________________________
JUDGE

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

———————– Page 50———————–

State Disbursements Unit VIA FACSIMILE: (217) 557-5093
P.O. Box 5400
Carol Stream, IL 60197-5400

To Whom It May Concern:

Re: (the name and number of your case)

Enclosed you will find a copy of the Uniform Order for Support and Child Support Data
Sheet filed in the above-referenced case. The payor is (the name of the person paying the
support), the payee is (the name of the person to receive the support), and the employer is
(the employer who will be withholding the child support). Please open an account for this
case so that the child support payments can be properly disbursed when received. You
may address your correspondence with the payee as follows:

(the name and address of the person who will receive the support)

Please feel free to call me if you have any questions in this regard.

Sincerely,

(your name and address)
enclosures

(The State Disbursement Unit prefers that the letter and enclosures be faxed to the number
above. If you cannot fax it, mail it to the address on the letter)

———————– Page 51———————–

Ms. Linda Stayton
Division of Child Support Enforcement
104 Airway Drive
Marion, IL 62959

Dear Ms. Stayton:

RE: (the name and number of your court case)

Please find enclosed a child support order and notice of withholding that was recently
entered by the Courts in the above case. I would appreciate it if you would log this into your
computer so that DCSE has the most up to date information in this matter.

If you have any questions, please do not hesitate to contact me.

Sincerely,

(your name and address)

enclosures

(If you do not live in Southern Illinois, you should find out the address of your local Division
of Child Support Enforcement and send this letter and the enclosures there)

———————– Page 52———————–

Certified Mail No.:

(name and address of employer)

Dear ***:

Re: (your case name and number, plus the name and social security number of the person paying
the support)

Please be advised that a child support order has been entered against (name of person that will be
paying the support). It is my understanding that he/she is employed by you. I have enclosed with
this letter a Notice for Withholding. This order provides for income withholding to enforce a court
ordered payment of support. You are required to withhold the amount of support from the earnings
of your emp loyee as follows:

1. Withhold the amount specified, (amount of support to be paid) per (how often the support is to
be paid, e.g. per month, per week, per 2 weeks, etc), beginning with the next payment of
earnings, following 7 days after you receive this notice. Withholdings must continue until (the
termination date on your Uniform Order for Support).

2. Forward payments withheld from the employee’s wages to: State Disbursement Unit, P.O. Box
5400, Carol Stream, Illinois 60197-5400. You should make the check payable to State
Disbursement Unit and provide the following information either on the check or a remittance
form:

a. Court Order No. (the number of your case);
b. Employee’s name and social security number; and
c. Amount withheld.

You will find attached a sample form.

3. The law prohibits you from and provides penalties for, discharging, disciplining or otherwise
penalizing any employee because of a duty to withhold earnings.

4. You are required to cooperate with the custodial parent or spouse whenever an employee
terminates his or her employment by providing information on new employment or other
whereabouts of the employee. You should return a copy of the Notice for Withholding to
(your name and address), immediately upon termination. In addition, whenever an employee
is no longer employed by you, you must return a copy of the Notice for Withholding to the
Circuit Court Clerk and furnish information about the employee’s whereabouts and new
employment. This is required under subsection (G)(2) of the Illinois Revised Statutes on
Income Withholding. I have enclosed a sample form for your convenience.

5. Amounts to be withheld are subject to the following limitations: Federal and state income
taxes, social security and statutory retirement, disability contributions, and union dues must
be withheld first. You must withhold a maximum of 50 percent of the remaining income for an
individual supporting another spouse or child and 60 percent for a person who is not.

———————– Page 53———————–

6. For withholding the income you are entitled to receive the lesser of a $5.00 per month or the
actual check processing cost to be taken from the income to be paid to the employee.

This Notice of Withholding takes precedence over any prior or subsequent garnishments,
attachments, wage assignments or other claims of creditors.

Thank you for your prompt attention to this matter.

Sincerely,

***

***

Enclosure

cc ***

———————– Page 54———————–

ATTENTION EMPLOYERS: Use this form when payment is directed to the State Disbursement Unit
(SDU).

State Disbursement Unit
P.O. Box 5400
Carol Stream, IL 60197-5400

This form should be sent each pay period along with your check made payable to the State
Disbursement Unit (SDU).

Deductions for more than one employee for court ordered child support may be reported on the
same remittance form and combined into one check.

Complete all boxes below for each employee included in your attached check to ensure proper
credit at the office of the State Disbursement Unit.

For State Disbursement Unit’s Use

___________________________________ Date Received___________________
Employer’s Name

___________________________________ Date Processed__________________
ATTN.

Employer’s
Address:________________________________________________________________

________________________________________________________________________

City State Zip
________________________________________________________________________

———————– Page 55———————–

Employee/ IV-D or Non IV-D
Obligor Name Court Order # *If Available Amount Withheld

(For additional remittance forms, please copy this form.)

———————– Page 56———————–

EMPLOYEE CHANGE OF INFORMATION AND RETURN OF
NOTICE OF WITHHOLDING

Person serving the order for withholding should put their name and address in this box.

Mail this form and a copy of the Notice for Withholding to:

(your name & address)

ATTENTION EMPLOYER:

When an employee, subject to an Notice for Withholding, is no longer employed by you, please
complete this form to the best of your ability and forward it along with a copy of the order for
withholding to the above address. This is required by statute.

EMPLOYEE NAME:______________________________

NEW EMPLOYER INFORMATION: (IF AVAILABLE)

NAME:_______________________________________

ADDRESS:____________________________________

CITY:_______________________________________

STATE & ZIP CODE:___________________________

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