Disclosure Statement
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82800 - Affidavit
(Rev. 6/07/06) CCDR 0604 A
3558 - Disclosure Statement Filed
IN THE CIRCUIT COURT OF ___________ COUNTY, ILLINOIS
COUNTY DEPARTMENT - DOMESTIC RELATIONS DIVISION
IN RE The
Marriage
Custody
}
Support
Parentage
____________________________________________________,
No. ______________________________________
Petitioner,
and
Calendar:
____________________________________________________,
Respondent.
DISCLOSURE STATEMENT
(Pursuant to Rule 13.3.1 (b)
STATE OF _______________________
}
ss:
COUNTY OF _____________________
Petitioner/Respondent, ______________________________________, being duly sworn, deposes and says that the following
is an accurate statement as of __________________________, ________, of my net worth (assets of whatsoever kind and nature
and wherever situated minus liabilities), statement of income from all sources, statement of monthly living expenses, statement of
health insurance coverage, and statement of assets transferred of whatsoever kind and nature and wherever situated:
Name: ____________________________________________
Telephone No.: __________________________________________
Address: __________________________________________
Date of Birth: ______________________________________________
__________________________________________________
Date of Dissolution of Marriage: ____________________________
(if applicable)
Date of Marriage: __________________________________
Parties reside in the same household: _____ Yes _____ No
Minor and/or Dependent Children of this __________ Marriage or __________ Parentage
Full Names
Age
DOB
Residing with
________________________________________
________
____________
_______________________________________
________________________________________
________
____________
_______________________________________
________________________________________
________
____________
_______________________________________
Current Employer: _____________________________________
Address: _________________________________________________
Self Employment: ______________________________________
Address: ________________________________________________
Other Employment: ____________________________________
Address: ___________________________________________________
______ Check if unemployed
Number of Paychecks per year (Please Circle)
12
24
26
52
Number of Exemptions claimed: __________
Number of Dependents claimed: __________
Gross income from all sources last year: ________________________________________________________________________________
Gross income from all sources this year through: ________________________________ : ______________________________________
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