Form 4A-101. Domestic relations information sheet.

DOMESTIC RELATIONS INFORMATION SHEET1 NOTE TO CLERK: DO NOT FILE THE INFORMATION SHEET Type or print responses. Required in all domestic relations cases.2 (Do not use in domestic violence cases.) A. Petitioner’s attorney information. (Complete only if Petitioner has an attorney.) Petitioner’s name: Attorney’s name: Attorney’s ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ address: City: State: Zip code: Telephone: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ B. Information regarding petitioner and respondent. (Do not use an attorney’s mailing address. Use a separate sheet if necessary.) Petitioner Name: ____________________________ (Last name, first, middle) Other names (e.g. maiden name): _________________________________ Address: _________________________ City: _____________________________ State: ____________________________ Zip code: _________________________ Date of birth: ______________________ Social Security number3: _____________ Respondent Name: ____________________________ (Last name, first, middle) Other names (e.g. maiden name): __________________________________ Address: __________________________ City: ______________________________ State: ____________________________ Zip code: __________________________ Date of birth: _______________________ Social Security number3: ______________ C. Parties’ minor children. (Provide the date of birth and social security number for each minor child, if any. Use a separate sheet if necessary.) Name: __________________________ (Last name, first, middle) Date of birth: _____________________ Social Security number: ____________ Name: __________________________ (Last name, first, middle) Date of birth: _____________________ Social Security number: ____________ Name: __________________________ (Last name, first, middle) Date of birth: _____________________ Social Security number: ____________ Name: __________________________ (Last name, first, middle) Date of birth: _____________________ Social Security number: ____________ D. Request to limit access to information. (Optional – complete only if applicable) [ ] The [petitioner] [respondent] has reason to fear domestic violence or child abuse. For this reason, please limit access to information about the [petitioner] [respondent] in the Child Support & Paternity Case Registry to the extent possible.4 The [petitioner] [respondent] realizes that this request may make it more difficult to assist in collecting child support. The [petitioner] [respondent] understands that the other party and the public might still view information about this case under some circumstances. I affirm that this request is legitimately made and not designed to harass or intimidate the other party or mislead the court. _____________________________________ Signature of Petitioner END OF INFORMATION SHEET