Form 171-470 - Lake County Court Form Page 3
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4Part C. Support (Check all that apply)
22.
The Respondent
is /
is not employed.
23.
The Respondent
is /
is not able to contribute to the support of
our child(ren)
and myself.
am /
24. I
am not (check one) seeking child support for my children because: ___________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
am /
25. I
am not (check one) seeking maintenance (support for a spouse/partner) because: ______________
__________________________________________________________________________________________
__________________________________________________________________________________________
Part D. Property
(Include all property you and your spouse/partner own.)
(Attach additional pages as needed)
26. The Respondent and/or I have the following marital/civil union property and debts. (Check all that apply)
Real Estate/House(s):
Street Address
Pension(s)/Retirement Accounts
Name of Company
Bank account(s) and investment(s):
Name of Financial Institution
Motor Vehicle(s):
Year, Make and Model
Debts (attach list)
Other:
I claim the following property as my non-marital/civil union property because the property was acquired
27.
prior to our marriage/civil union /
by gift /
by inheritance /
other: ___________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
I acknowledge the following property as the Respondent’s non-marital/civil union property because the property
28.
was acquired
prior to our marriage/civil union /
by gift /
by inheritance /
other: ________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Part E. Grounds for Dissolution
29. From on or about ______________________, my spouse/partner and I have lived separate and apart from each
(mm/dd/yyyy)
other for a continuous period and irreconcilable differences have caused the irretrievable breakdown of the
marriage/civil union.
Efforts at reconciliation have failed or future attempts at reconciliation would be
impracticable and not in the best interests of the family.
Part F. Parties’ Agreements
30.
The parties have reached agreement(s) on the following issues:
allocation of parental responsibility,
parenting time,
child support,
maintenance, (support for a spouse/partner)
property,
debts. State the
specific
arrangements:
________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(Attach additional pages as needed)
Page 3 of 4
#171-470 (Rev 12/15)
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