Family Law Case Information Sheet For
De Facto Custodian, Adoption and Minor Guardianship Cases 	Case Number (Clerk fills in case #):
	
	Exempt from Public Disclosure	

Fill out this form to start a new case or intervene in a Family Law case. 
The information you give us is private.

1.	Describe your case:	 De Facto Custodian    Minor Guardianship    Adoption        
					 Other (please list)										

						Case Number (Clerk will fill in case #)	

2.	Information about Petitioner/Guardian/De Facto Custodian
	
	Full Legal Name: 																                				First 	                            Middle 	                               Last 

	Any other names used:														

	Address: 																
						Street 					City 			State 		Zip 

	Phone numbers:															 	 						Home 			Work 				  	 Cell 	 

	Social Security Number	:				 Date of Birth:			Sex:  Male   Female
	
	Is English your first language?  Yes   No   If no, what language? _____________________	Do you speak, read and write English?     Yes   No   
	Do you need an interpreter? c Yes   c No 

3.	List all other people in your home. 

Name:												Age:					

Name:												Age:					

Name:												Age:					

Name:												Age:						
4.	Information about the biological or legal Mother of the Child(ren)

	Full Legal Name: 																                				First 	                            Middle 	                               Last 

	Any other names used:														

	Address: 																
						Street 					City 			State 		Zip 

	Phone numbers:															 	 						Home 			Work 				  	 Cell 	 

	Social Security Number	:					 Date of Birth:						

5.	Information about the biological or legal Father of the Child(ren)

	Full Legal Name: 																                				First 	                            Middle 	                               Last 

	Any other names used:														

	Address: 																
						Street 					City 			State 		Zip 

	Phone numbers:															 	 						Home 			Work 				  	 Cell 	 

	Social Security Number	:					 Date of Birth:						

6.  Information about each minor child that you are seeking guardianship or adoption for:

First Child’s Name: 							DOB:____________ SSN: ____________
 
With whom has the child lived with (check all that apply) [  ] Petitioner  [   ] Mother  [   ]  Father   

[   ] Other: 																	
                  			List all people the child has lived with in the last year

Second Child’s Name: 						DOB:____________ SSN: _____________
 
With whom has the child lived with (check all that apply) [  ] Petitioner  [   ] Mother  [   ]  Father   

[   ] Other: 																	
                  			List all people the child has lived with in the last year

Third Child’s Name: 							DOB:____________ SSN: _____________
 
With whom has the child lived with (check all that apply) [  ] Petitioner  [   ] Mother  [   ]  Father   

[   ] Other: 																	
                  			List all people the child has lived with in the last year

Fourth Child’s Name: 						DOB:____________ SSN:     __	_______
 
With whom has the child lived with (check all that apply) [  ] Petitioner  [   ] Mother  [   ]  Father   

[   ] Other: 																	
                  			List all people the child has lived with in the last year 

If you are seeking custody of more than four children, please provide their information on the back of this form.

7.	Are you aware of any other person besides the natural parents who claims to be a guardian or legal custodian of any of the minor child(ren) listed on this form (including attachments)?  [    ] YES  [   ] NO  If yes, what is the child’s name and what is the relationship to the child?     

Child’s name  	  			Relationship of person to child (for example, 
paternal grandmother, aunt, uncle, etc.)

8.	Other cases involving the children named on this form.
List any child support, protective order, domestic violence or child abuse cases, custody, adoption, or guardianship orders for the petitioner(s) and any child listed on this form:
Case Number	Date of Order 
(or date requested)	County / State	For which children?	Type of case	
1.				 Support	 Custody 
 Adoption	 Paternity
 Guardianship	
2.				 Support	 Custody 
 Adoption	 Paternity
 Guardianship	
3.				 Support	 Custody 
 Adoption	 Paternity
 Guardianship	
4.				 Support	 Custody 
 Adoption	 Paternity
 Guardianship	

9.  	Any cases involving violence or abuse:
List any protective order, domestic violence or child abuse case involving any adult or child listed on this form:
Case Number	Who was the order against?	Who did the order protect?	Date of Order (or date requested)	County/State	Type of case	
1.					 Domestic Violence 
 Child Abuse
 No Contact Order
 Other	
2.					 Domestic Violence 
 Child Abuse
 No Contact Order
 Other	
3.					 Domestic Violence 
 Child Abuse
 No Contact Order
 Other	
4.					 Domestic Violence 
 Child Abuse
 No Contact Order
 Other	

If there are other cases not listed on this sheet please continue on the back of page 3.