Illinois > Local County > 2nd Judicial Circuit
Pre Mediation Questionnaire 68 - Illinois
| Pre Mediation Questionnaire Form. This is a Illinois form and can be used in 2nd Judicial Circuit Local County . |
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STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE SECOND JUDICIAL CIRCUIT _________________ COUNTY IN RE THE MARRIAGE OF: ) ) ______________________________ ) Petitioner ) v. ) Cause No.:______________ ) ______________________________ ) Respondent ) PRE-MEDIATION QUESTIONNAIRE (To be completed by each party prior to referral for Judicial Mediation) Full Name:_________________________________________ Date of birth: __________________ Residence address: _____________________________ ____________________________ Mailing address (if different):___________________________________ ____________________________________ Home telephone no.: _________________________ Home fax no.(if applicable): __________________ Your attorneys name (if applicable): _____________________________ Your attorneys mailing address: _________________________________ _________________________________ Your attorneys office telephone no.: _____________________________ Your attorneys office fax no.: _________________________________ Do you know Judge Stephen G. Sawyer of Wabash County? ____Yes ____No If yes, what is the nature of your acquaintance and all contacts with Judge Sawyer? __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Pre-mediation Questionnaire 68 7/9/04 Page 1 of 5 <<<<<<<<<********>>>>>>>>>>>>> 2 Has Judge Sawyer acted as a judge in any case in which you are or were a party? ____Yes ____No Has Judge Sawyer acted as attorney or States Attorney in any case or any matter in which you have been involved? ____ Yes ____ No If you answered yes to either of the 2 preceding questions, please explain, and include whether or not the case or matter is nw pending, and, if noto , when it concluded. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Are you presently married? ____ Yes ____No If yes, to whom and since what date? _____________________________ _____________________________ Have you previously been married: ____ Yes ____ No If yes, to whom and during what period(s): _____________________________ _____________________________ _____________________________ Please state the names and dates of birth of all of your children, and the name of the other parent of each child. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please state the names and relationships (to you) of everperson residing with you on a y full-time basis. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ If any of the persons residing with you full-time are children who are the subjects of the pending court action, name those children and indicate how long they have lived with you on a full-time basis. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Pre-mediation Questionnaire 68 7/9/04 Page 2 of 5 <<<<<<<<<********>>>>>>>>>>>>> 3 ________________________________________________________________________ As to any children just named, please nameach one who attends school and specify the e school and the school schedule. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please state the names of any of your cildreh n of whom you are sole custodian. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please state the names of any of your cildreh n of whom you are a joint custodian (whether primary or not), and the name and rsidence address of the other joint custodiae n. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What is your occupation? _______________________ Where do you work? ______________________________________________________ If this location is outside the home, how far is it from your home?___________________ How long have you worked at this occupation in that location?_____________________ Please state your usual weekly work schedule. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do any of the children who are the subjects of the pending court action have special needs? If so, name those children and explain those needs. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Does someone other than his or her parents care for any of the children who are the Pre-mediation Questionnaire 68 7/9/04 Page 3 of 5 <<<<<<<<<********>>>>>>>>>>>>> 4 subjects of the pending court action? If so, name the care-giver,
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