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Form preview Child support affidavit form All Applicants/Substantial Owners are required to complete this affidavit and comply with the Child Support Enforcement Ordinance before any privilege is granted. Signature of this form constitutes a certification that the information provided below is correct and complete and that the individual s signing this form has/have personal knowledge of such information. Privilege Information County Department Applicant Information Last Name First Name Social Security - - MI Date of Birth Street Address City Home Phone State - Zip Driver s License Child Support Obligation Information The undersigned applicant being duly sworn on oath or affirmation hereby states that to the best of my knowledge place an X next to A B C or D A. Cook County Affidavit of Child Support Obligations Effective July 1 1998 every applicant for a County Privilege shall be in full compliance with any judicially or administratively ordered Child Support Obligation before such applicant is entitled to receive or renew a County Privilege. When Delinquent Child Support Obligation exists the County shall not issue or renew any County Privilege and may revoke any existing County Privilege. Applicant means any person or business entity including all Substantial Owners seeking issuance of a County Privilege or renewal of an existing County Privilege from the County. This term shall not include any political subdivision of the federal or state government including units of local government and notfor-profit organizations. County Privilege means any business license including but not limited to liquor dealers licenses packaged goods licenses tavern licenses restaurant licenses and gun licenses real property licenses or lease permit including but not limited to building permits zoning permits or approvals environmental certificate County HOME Loan and contracts exceeding the value of 10 000. Substantial Owner means any person or persons who own or hold a twenty-five percent 25 or more percentage of interest in any business entity seeking a proprietorship Substantial Owner means that individual or sole proprietor. The applicant has no judicially or administratively ordered child support obligations. the terms of the order. revoking the privilege. Signature Subscribed and sworn to before me this day of 20 Notary Public Date. Cook County Affidavit of Child Support Obligations Effective July 1 1998 every applicant for a County Privilege shall be in full compliance with any judicially or administratively ordered Child Support Obligation before such applicant is entitled to receive or renew a County Privilege. When Delinquent Child Support Obligation exists the County shall not issue or renew any County Privilege and may revoke any existing County Privilege. When Delinquent Child Support Obligation exists the County shall not issue or renew any County Privilege and may revoke any existing County Privilege. Applicant means any person or business entity including all Substantial Owners seeking issuance of a County Privilege or renewal of an existing County Privilege from the County.

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