Author: Chris Lewis

YOUR INFORMATION (this form is informal, providing the below information in any format is fine):

Name 									 DOB: 			Sex: ☐M ☐ F
	Last Name		First		Middle		Maiden			mm/dd/yyyy
Residential Address 												
Mailing Address 								       (only you receive mail at this address)
Home Phone: (	)		Work Phone: (		)		Cell Phone: (	     )		
Email Address: 						(Make sure your email account is secure)
Place of Employment: 				Address: 			
Basic Work Schedule: 						
Place of Birth									SSN				
				City			State				Social Security Number
Secondary Contact (In case of communication difficulty):
Name						Relationship			Phone Number		
Address								Email					

OPPOSING PARTY:

Name 									 DOB: 			Sex: ☐M ☐ F
	Last Name		First		Middle		Maiden			mm/dd/yyyy
Residential Address 												
Mailing Address 								       (only you receive mail at this address)
Home Phone: (	)		Work Phone: (		)		Cell Phone: (	     )		
Email Address: 						(Make sure your email account is secure)
Place of Employment: 				Address: 			
Basic Work Schedule: 						
Place of birth									SSN				
				City			State				Social Security Number

RELATIONSHIP:

Date / City of Marriage:				/							
Date / City of Separation:				/							

CHILDREN FROM THIS RELATIONSHIP:

Name:						DOB:			SSN:			 ☐ M ☐ F
Name:						DOB:			SSN:			 ☐ M ☐ F
Name:						DOB:			SSN:			 ☐ M ☐ F
Where child(ren) residing?									
Who carries medical insurance on the child(ren)?

Aaron Carnine • Black, Ballard, McDonald, P.C. • acarnine@illinoisfirm.com • (618) 242-3310
108 South 9^th Street, PO Box 4007, Mt. Vernon, Illinois 62864     v3.19.2020