ADOPTION, GUARDIANSHIP OF A MINOR, AND NAME CHANGE FM SUMMARY SHEET: M.R. Civ. P. 5(h) This form is used for entering basic information about the case and the parties into court records. You must complete and file this form with the Clerk when you file your Petition or Motion. You are not required to give a copy of this form to the other party(ies). COURT LOCATION (Where you are filing this action): TYPE OF ACTION (Check one box): Adoption Guardianship of a Minor Name Change TYPE OF FILING (Check one box): Original Proceeding Transferred Probate Matter, Original Docket # is: Post-Judgment Motion: Original Docket # is: to terminate guardianship of a minor. other:________________________________________. PETITIONER INFORMATION: (Person starting the action or if post-judgment, name of person who was the petitioner in the original case.) Name: First Middle Last Maiden Mailing Address: City State Zip Physical Address: City State Zip Gender: Home Telephone: Attorney's Name: Date of Birth: Social Security number disclosure required on separate form. Work Telephone: Bar ID#: CO-PETITIONER INFORMATION (IF APPLICABLE): Name: First Mailing Address: Middle Last City Maiden State Zip Physical Address: City State Zip Gender: Home Telephone: Attorney's Name: Date of Birth: Social Security number disclosure required on separate form. Work Telephone: Bar ID#: RESPONDENT INFORMATION: (Person being served or if post-judgment, name of person who was the respondent in the original case.) Name: First Middle Last Maiden Mailing Address: City State Zip PB-005, Rev. 10/16 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Physical Address: City State Zip Gender: Home Telephone: Attorney's Name: Date of Birth: Social Security number disclosure required on separate form. Work Telephone: Bar ID#: CO-RESPONDENT INFORMATION (IF APPLICABLE): Name: First Mailing Address: Middle Last City Maiden State Zip Physical Address: City State Zip Gender: Home Telephone: Attorney's Name: Date of Birth: Social Security number disclosure required on separate form. Work Telephone: Bar ID#: OTHER PARTY INFORMATION (IF APPLICABLE): Name: First Mailing Address: Middle Last City Maiden State Zip Physical Address: City State Zip Gender: Home Telephone: Attorney's Name: Date of Birth: Social Security number disclosure required on separate form. Work Telephone: Bar ID#: OTHER PARTY INFORMATION (IF APPLICABLE): Name: First Mailing Address: Middle Last City Maiden State Zip Physical Address: City State Zip Gender: Home Telephone: Attorney's Name: Date of Birth: Social Security number disclosure required on separate form. Work Telephone: Bar ID#: Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com PB-005, Rev. 10/16 MINOR CHILD(REN) INFORMATION: Full name: Date of Birth: Gender: Social Security number disclosure required on separate form. Social Security number disclosure required on separate form. Social Security number disclosure required on separate form. Social Security number disclosure required on separate form. Social Security number disclosure required on separate form. Date: Signature of Petitioner or Petitioner's Attorney Date: Signature of Co-Petitioner or Co-Petitioner's Attorney PB-005, Rev. 10/16 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com