EXPARTE TRO 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 (_______)______________________________(__ HOME TELEPHONE NUMBER ) STATE _____________________(_______)_______________________ WORK TELEPHONE NUMBER _________________________ ____________________________ DATE OF BIRTH ZIP CODE OTHER TELEPHONE NUMBER __________________________ SOCIAL SECURITY NUMBER ________________ DRIVER’S LICENSE NUMBER STATE OTHER PARENT _______________________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME _______________________________________________________________________________________________________________ OTHER NAMES USED OR NICKNAMES _______________________________________________________________________________________________________________ STREET ADDRESS CITY ________________________________________________ SOCIAL SECURITY NUMBER SEX: ____MALE ____ FEMALE RACE: STATE ________________________________________________ DRIVER’S LICENSE NUMBER _________ ____ BLACK ____ AMERICAN INDIAN ___ HAZEL ___ GREEN ___ GRAY ____ HISPANIC ____ PACIFIC ISLANDER HAIR COLOR: ___ BLACK ____ BLONDE ____ BROWN ____ Other ____ RED ____ GRAY ____Other Name: Name: DOB: DOB: DOB: Name: Name: DOB: Full Name: DOB: Full Name: DOB: Full Name: AKA: DOB: Full Name: AKA: DOB: Full Name: AKA: DOB: Full Name: AKA: DOB: Names of other adults living in your home AND Date of Birth Name: Name: Name(s) and Date of Birth of your child(ren): STATE DATE OF BIRTH: ________________ OR HEIGHT: __________ WEIGHT: _________ APPROX. AGE __________________ ____ WHITE ____ ASIAN EYE COLOR: ____ BLACK ____ BLUE ____ BROW ZIP CODE AKA: DOB: AKA: DOB: Date: ___________________ __________________________________________ _______________________________________________ (Type or print name) (Signature) FOR OFFICE USE ONLY Received by: _______________________________ Date: ______________ FamLaw-213/Rev. 3/14/07 American LegalNet, Inc. www.FormsWorkflow.com