If other existing restraining orders, protection orders, or criminal no-contact orders
Type of order _________________________________________
Name of court _________________________________________
Case number _________________________________________
Date of each order _________________________________________
Person getting custody _________________________________________
Person getting visitation _________________________________________
Confidential Party Information (2 forms and information in addition to above):
Case number
(Assigned by Clerk at counter) _________________________________________
Wife phone _________________________________________
Employer _________________________________________
Employer address _________________________________________
Health insurance _________________________________________
Policy number _________________________________________
Address _________________________________________
Social Security Number _________________________________________
Husband phone _________________________________________
Employer _________________________________________
Employer address _________________________________________
Health insurance _________________________________________
Policy number _________________________________________
Address _________________________________________
Social Security Number _________________________________________
Social Security Numbers of
Children under 18, born during the
marriage _________________________________________
Bureau of Vital Statistics Form (not court form, complete as much as possible):
Husband Current Residence _________________________________________
Place of Birth _________________________________________
Date of Birth _________________________________________
Financial Affidavit for Child Support (additional information combined with above):
If currently an order for support for minor children
Name of the court _________________________________________
Case number _________________________________________
Amount of support _________________________________________
Number of children _________________________________________
Name of your employer _________________________________________
Gross monthly income _________________________________________
If per hr, amount/# of hrs _________________________________________
If per mo, amount/bonuses _________________________________________