"Domestic Intake Worksheet Template"

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DOMESTIC INTAKE WORKSHEET
Style of Case:
__________________________________________
Case Number: ____________________________
Date of Filing:
____________________________
Judge Assigned to Case:____________________
Part A--
Information About the Parties
Petitioner/Plaintiff:
_____________________________________________________________________________________________
Name(s)
Address:
_____________________________________________________________________________________________________
Street Address
County
City
State
Zip
Telephone Number:
_____________________________________________________________________________________________
Home
Work
Date of Birth:
___________________________
Petitioner’s Attorney:
_____________________________________________________________________________________________
Name
Attorney’s Address:
_____________________________________________________________________________________________
Street Address
City
State
Zip
Attorney’s Telephone Number:
__________________________________________________________
Respondent/Defendant: _____________________________________________________________________________________________
Name(s)
Address:
_____________________________________________________________________________________________________
Street Address
County
City
State
Zip
Telephone Number:
_____________________________________________________________________________________________
Home
Work
Date of Birth:
___________________________
Respondent’s Attorney: _____________________________________________________________________________________________
Name
Attorney’s Address:
_____________________________________________________________________________________________
Street Address
City
State
Zip
Attorney’s Telephone Number:
________________________________________________
DOMESTIC INTAKE WORKSHEET
Style of Case:
__________________________________________
Case Number: ____________________________
Date of Filing:
____________________________
Judge Assigned to Case:____________________
Part A--
Information About the Parties
Petitioner/Plaintiff:
_____________________________________________________________________________________________
Name(s)
Address:
_____________________________________________________________________________________________________
Street Address
County
City
State
Zip
Telephone Number:
_____________________________________________________________________________________________
Home
Work
Date of Birth:
___________________________
Petitioner’s Attorney:
_____________________________________________________________________________________________
Name
Attorney’s Address:
_____________________________________________________________________________________________
Street Address
City
State
Zip
Attorney’s Telephone Number:
__________________________________________________________
Respondent/Defendant: _____________________________________________________________________________________________
Name(s)
Address:
_____________________________________________________________________________________________________
Street Address
County
City
State
Zip
Telephone Number:
_____________________________________________________________________________________________
Home
Work
Date of Birth:
___________________________
Respondent’s Attorney: _____________________________________________________________________________________________
Name
Attorney’s Address:
_____________________________________________________________________________________________
Street Address
City
State
Zip
Attorney’s Telephone Number:
________________________________________________
Part B--
Information About the Current Case and Related Cases
NUMBER OF CHILDREN:
NAMES OF CHILDREN:
Current Claim(s)/Issue(s)/Allegation(s):
9 9
Divorce
9 9
Legitimation
9 9
Adoption
9 9
Child Custody
9 9
Family Violence
9 9
Guardianship
9 9
9 9
9 9
Visitation
Child Abuse
Substance Abuse
9 9
9 9
9 9
Child Support
URESA
Other Issues:
9 9
Paternity
9 9
DHR
____________________________
____________________________
Is there currently pending in any other
County Court a case or cases involving the petitioner,
respondent, or anyminor children of the relationship?
9 9
Yes
9 9
No
If yes, please list the Court, Case number, and style of case below.
Court
Case Number
Style of Case
_______________________________
_______________________
_______________________________
_______________________________
_______________________
_______________________________
_______________________________
_______________________
_______________________________
_______________________________
_______________________
_______________________________
_______________________________
_______________________
_______________________________
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