IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
_____________________________________________ )
Petitioner
)
vs.
)
Case No. ________________________
)
)
_____________________________________________ )
Respondent
Declaration Under Uniform Child-Custody Jurisdiction
And Enforcement Act (UCCJEA) Pursuant to 750 ILCS 36/209
I,
_____________________________________________________ , certify that the following statements are true:
(Your full name)
1.
_____________________________________________________ and I are the parents of:
(Other parent’s full name)
____________________________________________________________
date of birth: _____________
(Child’s full name)
(mmddyyyy)
____________________________________________________________
date of birth: _____________
(Child’s full name)
(mmddyyyy)
____________________________________________________________
date of birth: _____________
(Child’s full name)
(mmddyyyy)
____________________________________________________________
date of birth: _____________
(Child’s full name)
(mmddyyyy)
____________________________________________________________
date of birth: _____________
(Child’s full name)
(mmddyyyy)
____________________________________________________________
date of birth: _____________
(Child’s full name)
(mmddyyyy)
(Attach additional pages as needed)
2. The child(ren) have lived at the following addresses in the past five years:
_________ to _________
___________________________________________
_______________________
(mmyyyy)
(mmyyyy)
Address
(With whom?)
_________ to _________
___________________________________________
_______________________
(mmyyyy)
(mmyyyy)
Address
(With whom?)
_________ to _________
___________________________________________
_______________________
(mmyyyy)
(mmyyyy)
Address
(With whom?)
_________ to _________
___________________________________________
_______________________
(mmyyyy)
(mmyyyy)
Address
(With whom?)
_________ to _________
___________________________________________
_______________________
(mmyyyy)
(mmyyyy)
Address
(With whom?)
_________ to _________
___________________________________________
_______________________
(mmyyyy)
(mmyyyy)
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): _________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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171-145 (Rev. 06/13)
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Declaration Under Uniform Child-custody Jurisdiction And Enforcement Act (uccjea) Pursuant To 750 Ilcs 36/209
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Declaration Under Uniform Child Custody Jurisdiction And Enforcement Act (uccjea) Form - The Court Of Common Pleas - Ohio
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