Free CSD-0053 - Illinois

(Rev. 4/19/01) CCSD 0053 CIRCUIT COURT OF COOK COUNTY APPLICATION FOR CHILD SUPPORT SERVICES WITH THE IV-D AGENCY
LAST NAME FIRST NAME MIDDLE NAME CITY
CAT.

IDPA USE ONLY CO/DIST. GRP. BASIC

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TELEPHONE NUMBER STATE

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STREET ADDRESS APT. NO. ZIP SOCIAL SECURITY NUMBER

_________
SEX

____/____/____
DATE OF BIRTH

__________________
RACE

I HEREBY APPLY TO THE CLERK OF THE CIRCUIT COURT/STATE'S ATTORNEY OF COOK COUNTY FOR THE FOLLOWING SERVICES:

____ CHILD SUPPORT SERVICES ( Includes Absent Parent Location, Support Enforcement and Collection, if Necessary.) NO FEE REQUIRED ____ PATERNITY DETERMINATION (Dose not include Support Enforcement and/or Collection Services.) NO FEE REQUIRED. ____ LOCATION SERVICE ONLY (Does not include Support Enforcement and/or Collection Services.) NO FEE REQUIRED.
I UNDERSTAND THAT:

1. The service requested DOES NOT include the obtaining of a divorce, enforcement of property settlements, or determination or enforcement of visitation and custody issues. I must retain a private attorney for these matters. 2. I must cooperate fully in all efforts to furnish the service requested. This includes supplying copies of any prior court orders, providing location leads, and giving necessary testimony at court hearings. 3. There is no guarantee that support payments will be obtained or the services rendered will be successful. 4. Support efforts may be discontinued if further action is inadvisable or legally impossible. 5. I must report any changes of my address promptly to the Clerk of the Circuit Court of Cook County, Room 200, 28 North Clark St., Chicago, Illinois 60602. I AGREE THAT: All support payments will be made payable to the Clerk of the Circuit court and will be forwarded to me. Indicate below each person currently dependent upon you for support (including yourself) and his/her gross income per month.
NAME FIRST LAST RELATIONSHIP SEX D. O. B.

Soc. Sec. Number

GROSS MONTHLY INCOME

Amount

Source

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I HEREBY AFFIRM THAT I AM THE CUSTODIAN OF THE CHILD(REN) FOR WHOM I SEEK SUPPORT SERVICES AND THAT I AM A RESIDENT OF THE STATE OF ILLINOIS. FURTHERMORE, I AUTHORIZE THE IV-D AGENCY OR ITS DESIGNEES TO EXPLORE, PURSUE, OR UTILIZE ALL SOURCES OF INFORMATION LEGALLY AVAILABLE TO IT IN SUPPORT OF ITS INVESTIGATIONS AND TO CHOOSE THE APPROPRIATE COURSE OF LEGAL ACTION.

TO THE BEST OF MY KNOWLEDGE, THE INFORMATION I HAVE SUPPLIED IS TRUE, CORRECT AND COMPLETE. APPLICANT'S SIGNATURE _________________________________________ INTERVIEWER'S SIGNATURE ______________________________________ DATE ________________________________ DATE _________________________________

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS