Ex Parte Intake Form (Cases With Children)
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1EX 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
FIRST NAME
MIDDLE NAME
________________________________________________________________________________________________________________
OTHER NAMES USED OR NICKNAMES
__________________________
CASE NUMBER
________________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
(_______)______________________________(_______)________________________________(_______)_________________________
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
OTHER TELEPHONE NUMBER
_________________________
____________________________
__________________________
_________________
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE NUMBER
STATE
OTHER PARENT
________________________________________________________________________________________________________________
LAST NAME
FIRST NAME
MIDDLE NAME
________________________________________________________________________________________________________________
OTHER NAMES USED OR NICKNAMES
________________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
_____________________________________________
_____________________________________________
________________
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE NUMBER
STATE
SEX: ____MALE ____ FEMALE
DATE OF BIRTH: ________________ OR
HEIGHT: __________ WEIGHT: _________
APPROX. AGE ______________
RACE:
____ WHITE
____ BLACK
____ HISPANIC
____ ASIAN
____ AMERICAN INDIAN
____ PACIFIC ISLANDER
____ Other
EYE COLOR:
HAIR COLOR:
____ BLACK
____ HAZEL
____ BLACK
____ RED
____ BLUE
____ GREEN
____ BLONDE
____ GRAY
____ BROW
____ GRAY
____ BROWN
____ Other
Name:
Name:
Name:
Name(s) and Date
of Birth of your
DOB:
DOB:
DOB:
child(ren):
Name:
Name:
Name:
DOB:
DOB:
DOB:
Date: ___________________
___________________________________
_________________________________________________
(Type or print name)
(Signature)
FOR OFFICE USE ONLY
Received by: ___________________________________
Date: ____________________
Local Court Form
FamLaw-213 Rev 4/30/12
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