Affidavit Of Parenting Time Supervisor Form - Lake County, Illinois

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IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
IN RE THE
MARRIAGE
PARENTAGE
)
SUPPORT
ALLOCATION OF
)
CIVIL UNION
PARENTAL RESPONSIBILITY
)
)
_______________________________________________
)
Case No. ________________________
)
vs.
)
)
)
______________________________________________
)
)
AFFIDAVIT OF PARENTING TIME SUPERVISOR
I, __________________________________________, state as follows:
(Print Name)
1. I reside at: __________________________________________________________________________________
(Street Address, City, State, Zip)
2. My telephone number is: ______________________________________________________________________
3. My relationship to the parties is: ________________________________________________________________
4. I accept the responsibility to supervise the parenting time of __________________________________________
pursuant to the order of this court dated __________________________.
5. My signature on this affidavit certifies that I will require that the parent with parenting time follow these rules of
conduct:
a. No discussion with the child(ren) about the divorce and/or any petition for order of protection.
b. No discussion with the child(ren) about the other parent’s activities.
c. No use of alcohol or drugs.
d. No abusive language.
e. No hitting or striking.
f.
No physical discipline.
g. No threatening behavior.
6. I will cancel the parenting time session if the parent with parenting time arrives for parenting time under the
influence of alcohol or drugs.
7. I will terminate a parenting time session if, at any time, it is necessary to protect the child(ren)’s best interests.
8. I acknowledge my responsibility to account to the court for compliance with the Order for supervised parenting
time.
Under penalties as 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.
_____________________________________________
Dated this _____ day of __________________,20_____
Signature
_____________________________________________
Printed Name
* Any person who makes a false statement, material to the issue or point in question, which he does not believe to be
true, in any document certified by such person in accordance with 735 ILCS 5/1-109 shall be guilty of a Class 3 felony
punishable by two (2) to five (5) years imprisonment and/or a $25,000.00 fine.
171-333 (Rev. 12/15)

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