Ex Parte TRO Intake Form (Cases With Children) {FamLaw-213}

EX PARTE INTAKE FORM (CASES WITH CHILDREN) Office Use Only __Change of Custody __Other __Initial Custody Order How This Form Will Be Used This form is CONFIDENTIAL and will not be part of the public file in this case. You are required to complete and submit this form to the court. THIS INFORMATION IS FOR OFFICIAL USE ONLY. If you are seeking a custody order, the information you provide will be used by the court to assist the court in conducting a background check on all parties seeking custody of the minor child(ren) subject to this action for the purpose of determining whether to award custody to you. You must provide a response to each item. ****CONFIDENTIAL**** PRINT ONLY YOUR INFORMATION ________________________________________________________________________________________________________________ LAST NAME OTHER NAMES USED OR NICKNAMES FIRST NAME MIDDLE NAME ________________________________________________________________________________________________________________ __________________________ CASE NUMBER ________________________________________________________________________________________________________________ STREET ADDRESS HOME TELEPHONE NUMBER CITY WORK TELEPHONE NUMBER STATE ZIP CODE (_______)______________________________(_______)________________________________(_______)_________________________ OTHER TELEPHONE NUMBER _________________________ DATE OF BIRTH ____________________________ SOCIAL SECURITY NUMBER __________________________ DRIVER'S LICENSE NUMBER _________________ STATE OTHER PARENT ________________________________________________________________________________________________________________ LAST NAME OTHER NAMES USED OR NICKNAMES FIRST NAME MIDDLE NAME ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ STREET ADDRESS SOCIAL SECURITY NUMBER CITY DRIVER'S LICENSE NUMBER STATE ZIP CODE _____________________________________________ SEX: ____MALE ____ FEMALE RACE: ____ WHITE ____ ASIAN EYE COLOR: ____ BLACK ____ BLUE ____ BROW _____________________________________________ ________________ STATE DATE OF BIRTH: ________________ OR APPROX. AGE ______________ ____ BLACK ____ AMERICAN INDIAN HEIGHT: __________ WEIGHT: _________ ____ HISPANIC ____ PACIFIC ISLANDER ____ RED ____ GRAY ____ Other ____ Other ____ HAZEL ____ GREEN ____ GRAY HAIR COLOR: ____ BLACK ____ BLONDE ____ BROWN Name(s) and Date of Birth of your child(ren): Name: DOB: Name: DOB: Name: DOB: Name: DOB: ___________________________________ (Type or print name) Name: DOB: Name: DOB: _________________________________________________ (Signature) Date: ___________________ FOR OFFICE USE ONLY Received by: ___________________________________ Date: ____________________ Local Court Form FamLaw-213 Rev 4/30/12 American LegalNet, Inc. www.FormsWorkFlow.com