Ccdr 0604A Form – Fill Out and Use This PDF

The CCDR 0604A form is a comprehensive document used in the Circuit Court of Cook County, Illinois, primarily within the County Department, Domestic Relations Division. It encompasses a variety of sections including affidavits, disclosure statements, and financial declarations pertinent to cases involving marriage, civil unions, custody, support, or parentage. If you're navigating through such legal matters, ensure you accurately fill out this form by clicking the button below.

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Ccdr 0604A Form PDF Details

In the entangled processes of legal disputes, particularly in the realm of domestic relations, the CCDR 0604A form stands as a crucial document within the Circuit Court of Cook County, Illinois. This multi-faceted form aims to streamline the complexities accompanying proceedings such as marriage, civil union, custody, support, and parentage cases by requiring detailed financial disclosure from the parties involved. The CCDR 0604A mandates the submission of comprehensive personal and financial data, encompassing net worth, income sources, monthly living expenses, health insurance coverage, and records of asset transfers. It serves as a foundational affidavit for ensuring equitable resolutions by facilitating a transparent view of each party's fiscal standing. The inclusion of specific sections for income statement and monthly living expenses, alongside directives for disclosing assets and liabilities, underscores its role in fostering an informed judicial review. By encompassing a wide array of financial aspects—from salaries, benefits, and other income types to expenditures across household, transportation, personal, and children-related categories—it underscores the exhaustive nature of information necessary for the courts to make judicious decisions regarding financial obligations and rights among parties. This detailed capture of economic realities further extends to liabilities and contingent obligations, offering a full spectrum view critical for the proceedings in the Domestic Relations Division.

Question	Answer
Form Name	Ccdr 0604A Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	disclosure statement relations sample, disclosure financial cook, 2800 disclosure financial form, ccdr il

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2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 A

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION

In Re the:  Marriage  Civil Union  Custod  Support  Parentage

______________________________________________________

Petitioner

and

______________________________________________________

Respondent

No. ___________________________________

Calendar: ______________________________

DISCLOSURE STATEMENT

(Pursuant to Rule 13.3.1)

STATE OF_______________________

COUNTY OF ____________________

ss:

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 situation minus liabilities), statement of income from all sources, statement of monthly living expenses, statement of health insur- ance 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/Civil Union: _________________
	(if applicable)

Date of Marriage/Civil Union: ___________________________

Parties reside in the same household:	 Yes  No
Minor and/or Dependent Children of this  Marriage		 Civil Union or
Full Name(s)	Age	DOB

Parentage:

Residing with

___________________________________	__________	__________		____________________________________________
___________________________________	__________	__________		____________________________________________
___________________________________	__________	__________		____________________________________________
Current Employer: ____________________________________			Address: ______________________________________________
Self Employment:_____________________________________			Address: ______________________________________________
Other Employment: ___________________________________			Address: ______________________________________________
 Check if unemployed
Number of Paychecks per year  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: _____________________________________________________________________

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

Page 1 of 10

2800 - Aidavit
3558 - Disclosure Statement Filed
3128 - Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 B

	Case No. ____________________________
STATEMENT OF INCOME	as of _______________________________
Gross Monthly Income
Salary/wages/base pay _______________________________________________________________		$ ___________________
Overtime/commission_______________________________________________________________		___________________
Bonus ___________________________________________________________________________		___________________
Draw____________________________________________________________________________		___________________
Pension and retirement beneits________________________________________________________		___________________
Annuity__________________________________________________________________________		___________________
Interest income ____________________________________________________________________		___________________
Dividend income __________________________________________________________________		___________________
Trust income______________________________________________________________________		___________________
Social Security_____________________________________________________________________		___________________
Unemployment beneits _____________________________________________________________		___________________
Disability payment _________________________________________________________________		___________________
Worker’s compensation ______________________________________________________________		___________________
Public Aid/Food stamps _____________________________________________________________		___________________
Investment income _________________________________________________________________		___________________
Rental income_____________________________________________________________________		___________________
Business income ___________________________________________________________________		___________________
Partnership income _________________________________________________________________		___________________
Royalty income ____________________________________________________________________		___________________
Fellowship/stipends_________________________________________________________________		___________________
Other income (specify) ______________________________________________________________		___________________
Total Gross Monthly Income		$ ___________________
Required Monthly Deductions
Federal Tax (based on ___________ exemptions) __________________________________________		$ ___________________
State Tax (based on __________ exemptions)_____________________________________________		___________________
FICA (or Social Security equivalent) ____________________________________________________		___________________
Medicare Tax______________________________________________________________________		___________________
Mandatory retirement contributions required by law
or as a condition of employment _______________________________________________________		___________________
Union Dues (Name of Union:_______________________________ ) _________________________		___________________
Health/Hospitalization Premiums ______________________________________________________		___________________
Prior obligations(s) of support actually paid pursuant to Court order ___________________________		___________________
Expenditures for repayment of debts that represent reasonable and
necessary expenses for the production of income (identify and itemize)__________________________		___________________
Medical expenditures necessary to preserve life or health _____________________________________		___________________
Reasonable expenditures for the beneit of the child and the other parent exclusive
of gifts (for non-custodial parent only) (Identify and itemize on a separate sheet) __________________		___________________
Total Required Deductions From Income		$ ___________________
	Net Monthly Income	$ ___________________

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

Page 2 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 C

		Case No. ____________________________
STATEMENT OF MONTHLY LIVING EXPENSES		as of _______________________________

1.Household

a.	Mortgage or rent (specify)______________________________________________________	$ ___________________
b.	Home equity payment ________________________________________________________	___________________
c.	Real estate taxes, assessments____________________________________________________	___________________
d.	Homeowners or renters insurance________________________________________________	___________________
e.	Heat/fuel __________________________________________________________________	___________________
f.	Electricity __________________________________________________________________	___________________
g.	Telephone (include long distance/cellular/fax or modem lines) __________________________	___________________
h.	Water and sewer _____________________________________________________________	___________________
i.	Refuse removal ______________________________________________________________	___________________
j.	Laundry/dry cleaning _________________________________________________________	___________________
k.	Maid/cleaning service _________________________________________________________	___________________
l.	Furniture and appliance repair/replacement ________________________________________	___________________
m. Repairs and maintenance to dwelling _____________________________________________		___________________
n. Lawn and garden/snow removal _________________________________________________		___________________
o. Food (groceries, household supplies, etc.) __________________________________________		___________________
p. Liquor, beer, wine, etc. ________________________________________________________		___________________
q. Cable/satellite TV ____________________________________________________________		___________________
r.	Internet Service Provider_______________________________________________________	___________________
s.	Other (specify) ______________________________________________________________	___________________
SUBTOTAL HOUSEHOLD EXPENSES:		$ ___________________

2.Transportation

a.	Gasoline ___________________________________________________________________	$ ___________________
b.	Repairs and Maintenance ______________________________________________________	___________________
c.	Insurance/license/city stickers ___________________________________________________	___________________
d.	Payments/replacement ________________________________________________________	___________________
e.	Alternative transportation ______________________________________________________	___________________
f.	Parking ____________________________________________________________________	___________________
g. Other (specify) ______________________________________________________________		___________________
SUBTOTAL TRANSPORTATION EXPENSES:		$ ___________________

3.Personal

a. Clothing ___________________________________________________________________ $ ___________________

b.	Grooming__________________________________________________________________	___________________
c.	Medical (after insurance proceeds/reimbursement)
	(1) Doctor _________________________________________________________________	___________________
	(2) Dentist _________________________________________________________________	___________________
	(3) Optical _________________________________________________________________	___________________
	(4) Medication ______________________________________________________________	___________________
d.	Insurance
	(1) Life (term)_______________________________________________________________	___________________
	(2) Life (whole or annuity) _____________________________________________________	___________________
	(3) Medical/Hospitalization ____________________________________________________	___________________
	(4) Dental/Optical ___________________________________________________________	___________________
e.	Other (specify) ______________________________________________________________	___________________
SUBTOTAL PERSONAL EXPENSES:		$ ___________________

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

Page 3 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 D

		Case No. ____________________________

4.Miscellaneous

a.	Clubs/social obligations/entertainment (including dining out) __________________________	$ ___________________
b.	Newspapers, magazines, books __________________________________________________	___________________
c.	Gifts ______________________________________________________________________	___________________
d.	Donations, church or religious ailiation __________________________________________	___________________
e.	Vacations (not including children) _______________________________________________	___________________
f.	Computer/Supplies/Software ___________________________________________________	___________________
g. Other (specify) ______________________________________________________________		___________________
SUBTOTAL MISCELLANEOUS EXPENSES:		$ ___________________

5.Minor and/or Dependent Children

a. Clothing ___________________________________________________________________ $ ___________________

b.	Grooming__________________________________________________________________	___________________
c.	Education
	(1) Tuition _________________________________________________________________	___________________
	(2) Books/Fees ______________________________________________________________	___________________
	(3) Lunches ________________________________________________________________	___________________
	(4) Transportation ___________________________________________________________	___________________
	(5) School-sponsored activities __________________________________________________	___________________
d.	Medical (after insurance proceeds):
	(1) Doctor _________________________________________________________________	___________________
	(2) Dentist _________________________________________________________________	___________________
	(3) Optical _________________________________________________________________	___________________
	(4) Medication ______________________________________________________________	___________________
e.	Allowance __________________________________________________________________	___________________
f.	Child/Pre-school/After-school care (not included elsewhere)____________________________	___________________
g.	Sitters _____________________________________________________________________	___________________
h.	Lessons/extracurricular activities/supplies __________________________________________	___________________
i.	Clubs/Summer Camps ________________________________________________________	___________________
j.	Vacations (children only) ______________________________________________________	___________________
k.	Other activities ______________________________________________________________	___________________
l.	Entertainment ______________________________________________________________	___________________

m. Other (specify) (e.g. gifts children give to others) ____________________________________	___________________
SUBTOTAL CHILDREN’S EXPENSES:	$ ___________________
TOTAL MONTHLY LIVING EXPENSES	$ ___________________

STATEMENT OF LIABILITIES

NOTE: Identifeditors, but DO NOT DUPLICATE monthlve as a monthllease use

Supplemental Statement of Liabilities (Part J of this form) if more space is needed to complete this section.

			MINIMUM
CREDITOR NAME	PAYMENT FOR	BALANCE DUE	MONTHLY PAYMENT
_____________________________________________	_____________________	$ ______________	___________________
_____________________________________________	_____________________	$ ______________	___________________
_____________________________________________	_____________________	$ ______________	___________________
_____________________________________________	_____________________	$ ______________	___________________
_____________________________________________	_____________________	$ ______________	___________________
SUBTOTAL MONTHLY DEBT SERVICE:			$ ___________________

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

Page 4 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 E

Case No. ____________________________

RECAPITULATION
NET MONTHLY INCOME ________________________________________________	$ ___________________
TOTAL MONTHLY LIVING EXPENSES _______________________________________	___________________
DIFFERENCE BETWEEN NET INCOME AND EXPENSES ____________________________	___________________
LESS MONTHLY DEBT SERVICE ___________________________________________	___________________
INCOME AVAILABLE PER MONTH _________________________________________	___________________


CONTINGENT LIABILITIES
(Provide potential obligor, claimant, basis of claim, date incurred, amount claimed, who incurred.)

___________________________________________________________________________________________________________

Have you ever iled for Bankruptcy?  Yes  No

If so, when? Date _________________________ Case No. _________________________________

Additional Cash Flow (monthly) (Identify but do not add to monthly income)

Spousal Support Received

(Payments received from prior Judgment or Support orders in other actions): ____________________________________________

	Case No. _____________________________________
Child Support Received
(Payments received pursuant to Court order in this action):	________________________________________

(Payments received pursuant to Court order in other actions): _________________________________________

Case No.: ________________________________________

STATEMENT OF ASSETS

he date of valuation is ___________________________ unless otherwise speciied. Please designate values. In prejudgment dissolution

of marriage/civil union actions, please indicate whether the property is marital/civil union (M or CU) non-marital/civil union Respondent (NMR or NCUR) non-marital/civil union Petitioner (NMP or NCUP). Please use Supplemental Statement of Assets (Part I of this form)

if more space is needed to complete this section.
		M/NMP/NMR/
Description of Asset	Title in Name of	CU/NCUP/NCUR	Value

CASH or CASH EQUIVALENTS (Do not list account numbers):

1.Savings or interest-bearing accounts ___________________________________________________________________________

_______________________________________________________________________________________________________

2.Checking Accounts ________________________________________________________________________________________

_______________________________________________________________________________________________________

3.Certiicates of Deposit______________________________________________________________________________________

_______________________________________________________________________________________________________

4.Money Market Accounts____________________________________________________________________________________

_______________________________________________________________________________________________________

5.Cash ___________________________________________________________________________________________________

_______________________________________________________________________________________________________

6.Other (specify) ___________________________________________________________________________________________

_______________________________________________________________________________________________________

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

Page 5 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 F

		Case No. ____________________________

INVESTMENT ACCOUNTS and SECURITIES:

1.Stocks ______________________________________________________________________________________________

2.Bonds ______________________________________________________________________________________________

3.Tax exempt securities ___________________________________________________________________________________

4.Secured or Unsecured Notes _____________________________________________________________________________

5.Other (specify): _______________________________________________________________________________________

REAL PROPERTY

(Provide address, type and description, amounts of mortgages, loans or liens)

1.Residence____________________________________________________________________________________________

2.Secondary or vacation residence ___________________________________________________________________________

3.Investment or Business Real Estate_________________________________________________________________________

4.Vacant Land__________________________________________________________________________________________

5.Other (specify)________________________________________________________________________________________

MOTOR VEHICLE(S): Boats, Trailers, etc. (Provide year, model, make, lien, debtor, amount)

___________________________________________________________________________________________________________

BUSINESS INTERESTS: Corporations, Partnerships, Sole Proprietorships (Provide percentage interest and number of shares, name of business, type of business, type of entity, current accounts receivable, current bank account balances, current inventory value)

___________________________________________________________________________________________________________

INSURANCE POLICIES: Life, medical, disability, business overhead, property, etc. (Provide type of insurance, insurer, policy number, name of insured, owner of policy, face amount, beneiciary, face value, cash value, surrender value, current death beneits)

___________________________________________________________________________________________________________

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

Page 6 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 G

		Case No. ____________________________

PENSION PLANS, IRA ACCOUNTS, DEFERRED COMPENSATION, ANNUITIES, 401K, etc.: (Provide name and type of plan, trustee of plan, nature of interest, beneiciary, vested or non-vested, current value)

___________________________________________________________________________________________________________

STOCK OPTIONS, ESOPS, OTHER DEFERRED COMPENSATION OR EMPLOYMENT BENEFITS: (Describe)

___________________________________________________________________________________________________________

INCOME TAX REFUNDS: Federal and State (Identify tax year)

___________________________________________________________________________________________________________

CHOSES IN ACTION: (Provide date of occurrence, nature/amount of claim, date suit iled, case number, name of plainti s)

___________________________________________________________________________________________________________

COLLECTIBLES: (Coins, stamps, art, antiques, etc.)

___________________________________________________________________________________________________________

ALL OTHER PROPERTY: (Personal or Real, NOT PREVIOUSLY LISTED valued in excess of $500.00)

___________________________________________________________________________________________________________

STATEMENT OF ASSETS TRANSFERRED OR SOLD

List all assets transferred or sold in any manner during the preceding three (3) years, or length of marriage, whichever is shorter (transfers or sales in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be speciically disclosed where such assets are otherwise identiied in the statement of net worth.)

	To Whom Transferred or Sold and			Amount
Description of Propert	Relationship to Transferee	Date of Transfer	Value	Received

______________________________ ______________________________ ______________ ____________ _____________

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

Page 7 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 H

		Case No. ____________________________

STATEMENT OF HEALTH INSURANCE COVERAGE

Currently eective health insurance coverage?

 Yes

No

Name of insurance carrier: ______________________________________________ Policy or Group No._______________________

Type of insurance:

Medical

Dental

Optical

Deductible: Per individual $_____________________________________ Per family $______________________________________

Persons covered:

Type of Policy:

Provided by:

Monthy cost:

 Self

HMO

Employer

Paid by employer

Spouse

PPO

 Private Policy

 Dependents

Full indemnity

 Other Group

 Paid by employee

$______________ for dependent per month

$_______________ for myself per month

he foregoing Asset Disclosure Statement has been carefully read by the undersigned who states under oath, under penalties as provided by law pursuant to 735 ILCS 5/1-109, that s/he has knowledge of the matters stated and that the statements set forth in this Aidavit are true and correct, except as to matters speciically stated to be on information and belief, and as to such matters the undersigned certiies as aforesaid that s/he believes same to be true.

_________________________________________________

Signature of Party

 Petitioner  Respondent

_________________________________________________

Type or Print Name

Signed and sworn to before me

_________________________________________, ____________

______________________________________________________

Notary Public

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

Page 8 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/15/14) CCDR 0604 I

		Case No. ____________________________

Supplemental Statement of Assets

________________________________________________________________________________________________

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

Page 9 of 10

2800	- Aidavit
3558	- Disclosure Statement Filed
3128	- Answer to Asset/Financial Disclosure Statement Filed	(Rev. 12/22/13) CCDR 0604 J

		Case No. ____________________________

Supplemental Statement of Liabilities

_________________________________________________________________________________________

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

Page 10 of 10

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Business income, Total Gross Monthly Income, and Fellowshipstipends in disclosure financial cook

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Ccdr 0604A Form – Fill Out and Use This PDF

Ccdr 0604A Form PDF Details

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