P.O. Box 4007, Mt. Vernon, IL 62864 Telephone: 618-242-3310 | Fax: 618-242-3735


Financial Affidavit Complete this Financial Affidavit and return it with a recent pay stub, W2, tax return, or other evidence of income. Hand-write costs using monthly figures where appropriate. If you have a question or explanation for a particular item, hand-write that information. Feel free to a new category or to modify an existing category to better suit your situation.  With each figure be able to explain how you arrived at that number.

Signature lines  This file contains signature variations for most eventualities.  Nothing will be filed without your knowledge and confirmation.

Pre-Mediation Questionnaire  Disputed decision making or parenting time issues must be mediated.  This questionnaire is to be completed by each parent prior to referral to mediation to give the mediator an overview of your situation and your requests.  Once completed, return it, it is filed under seal and neither party will see the other’s questionnaire

Notice of Intent to Exercise Parenting Time Use this form to be clear and provide proof that specific visitation time has been requested.  Keep a copy for yourself and mail/email the Notice to the other parent.  This is helpful to clearly confirm, for example, selected summer Parenting Time. Using is the better resource for this Notice

Support Remittance Form Use this form to send child support payments directly to the Illinois State Disbursement Unit. A new employer will not start withholding child support, you have to be proactive to pay voluntarily.  Child support does not go away and missed payments can accrue interest.

Gross to Net Income Conversion Table This table is used to convert both parent’s gross income into net income for purposes of determining child support based upon Illinois’ income shares model.

Income Shares Schedule This table is to determine the amount of child support to which children would be entitled when combining the net income of both parents, as determined from the Gross to Net conversion table.