SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO FAMILY COURT SERVICES 400 COUNTY CENTER, 6TH FLOOR REDWOOD CITY CA 94063 TEL: (650) 261-5080 FAX: (650) 261-5142 INFORMATION SHEET DAY OF COURT MEDIATION CONFIDENTIAL YOUR NAME:_____________________________________________ CASE NUMBER____________________________ OTHER NAMES YOU HAVE USED:_____________________________________________________________________ BIRTHDATE:_____________________________BIRTHPLACE:_____________________________AGE:_____________ SOCIAL SECURITY NUMBER:________________________DRIVER'S LICENSE NUMBER:_______________________ HOME ADDRESS:___________________________CITY:_______________ ZIP CODE:______________STATE:______ MAILING ADDRESS:_________________________CITY:_______________ ZIP CODE:______________STATE:______ TELEPHONE #:HOME _____________________________ WORK/MESSAGE___________________________________ YOUR ATTORNEY:_______________________________________ TELEPHONE NUMBER:_______________________ CHILDREN INVOLVED IN THIS CASE: NAME ____________________________________ ____________________________________ ____________________________________ ____________________________________ DOB ________________________ ________________________ ________________________ ________________________ SCHOOL _________________________________ _________________________________ _________________________________ _________________________________ YOUR EMPLOYMENT INFORMATION: EMPLOYER_____________________________________________ADDRESS__________________________________ DATE EMPLOYED ______________________ WORK SCHEDULE ___________________________________________ JOB TITLE _______________________________ MONTHLY INCOME BEFORE TAXES __________________________ RESIDENCE HOW LONG IN YOUR PRESENT ADDRESS? _______________ ARE YOU MOVING? ( ) NO ( ) YES ___________ HOW MANY BEDROOMS? ________________ NUMBER OF PEOPLE IN YOUR HOME __________________________ ALL OTHERS RESIDING IN YOUR RESIDENCE AND THEIR RELATIONSHIP TO YOU: __________________________________________________________________________________________________ STATUS OF YOUR RELATIONSHIP WITH THE OTHER PARENT: MARRIED: ( ) YES ( ) NO , IF DIVORCED, DATE DIVORCE WAS FINAL:_____________________________________ DATE BEGAN LIVING TOGETHER: ______________________DATE OF LAST SEPARATION:_____________________ NAME OF CURRENT SPOUSE/DOMESTIC PARTNER: _____________________________________________________ LIST NAMES AND AGES OF CHILDREN OF THIS RELATIONSHIP: ___________________________________________ HEALTH ARE YOU RECEIVING MEDICAL TREATMENT? ( ) NO ( ) YES, BRIEFLY DESCRIBE__________________________ DOMESTIC VIOLENCE: WHERE THERE IS A HISTORY OF DOMESTIC VIOLENCE AND /OR A RESTRAINING ORDER IN EFFECT, THE PROTECTED PERSON MAY REQUEST SEPARATE MEDIATION UNDER FAMILY CODE 3181 AND/OR BRING A SUPPORT PERSON UNDER FAMILY CODE 6303. PLEASE DESCRIBE. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ HAS CHILD PROTECTIVE SERVICES BEEN INVOLVED?_________________________________________________ HAS A PETITION BEEN FILED( W & I 300)?_____________________________________________________________ HAVE THE CHILDREN WITNESSED DOMESTIC VIOLENCE?______________________________________________ I WISH TO HAVE SEPARATE MEDIATION _______ I WISH TO HAVE A SUPPORT PERSON ________ CURRENT PROBLEMS_______________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ REASONABLE SOLUTIONS __________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _______________________________________________________________________________________________ I CERTIFY THAT ALL THE INFORMATION PROVIDED TO FAMILY COURT SERVICES IS TRUE AND CORRECT. I UNDERSTAND THAT FALSIFICATION OR OMISSION OF ANY INFORMATION MAY AFFECT THE DISPOSITION OF MY CASE, AND THAT THE FAMILY COURT SERVICES STAFF MAY CONSIDER ALL OTHER AVAILABLE FAMILY COURT SERVICES CASE INFORMATION REGARDING MYSELF. SIGNATURE ____________________________________________________ DATE ___________________________ FCS-5 [Rev. 05/05] www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com