FAMILY COURT FILING CERTIFICATE - Must Be Printed In assigning cases to the divisions of the Family Court, the judges wish to utilize the concept of “one judge-one-family”. It is, therefore, necessary that the Court be informed of any prior litigation involving the family. This form must be completed by the attorney or pro se party filing an initial pleading or application in the Family Court. INSTRUCTIONS _________________________________________________ Petitioner/Minor Child _________________________________________________ √ vs. _________________________________________________ Respondent Type or neatly print in black ink. √ Last 4 Digits of SSN Fill in the two-letter Case Type code from the back of this form here _________. _________________________________________________ Last 4 Digits of SSN MOTHER/CHILDREN (Name, DOB, Last 4 Digits of SSN) Pending Actions Is there any action pending in the Family Court involving any of the parties or any child/ren of a party to this action? □ Yes □ No If yes, print the style of the case(s), case number, and type of action (use additional form if necessary): _________________________________________________ _________________________________________________ Petitioner/Minor Child Petitioner/Minor Child (DOB) (DOB) _________________________________________________ _________________________________________________ Last 4 Digits of SSN Last 4 Digits of SSN vs. vs. _________________________________________________ _________________________________________________ Respondent Respondent _________________________________________________ _________________________________________________ Last 4 Digits of SSN Last 4 Digits of SSN _________________________________________________ _________________________________________________ Case Number Case Number Division Filing Date Division Filing Date _________________________________________________ _________________________________________________ Type of Action Type of Action Prior Litigation □ □ Has a party or child of a party been involved in any prior litigation in the Family Court? Yes No If yes, print the style of the case(s), case number and type of action (use additional form if necessary): _________________________________________________ _________________________________________________ Petitioner/Minor Child Petitioner/Minor Child (DOB) (DOB) _________________________________________________ _________________________________________________ Last 4 Digits of SSN Last 4 Digits of SSN vs. _________________________________________________ vs. _________________________________________________ Respondent Respondent _________________________________________________ Last 4 Digits of SSN _________________________________________________ Last 4 Digits of SSN _________________________________________________ Case Number Division _________________________________________________ Disposition Date Case Number Division Filing Date _________________________________________________ Type of Action _________________________________________________ Type of Action Notice of Parent Education / Mediation Programs If filing Petition for Dissolution, Legal Separation, or a Motion to Modify involving custody or visitation, I have provided the Petitioner/Respondent the Court Notice of Mediation and Parent Education Programs (Form CCFC74) and attached a copy of the same form to the service copy. If custody or visitation is an issue, I either filed a parenting plan with the pleading or understand that a parenting plan must be filed within 30 days of service of process, entry of appearance, or filing of an answer. ___________________________ ______________________ Attorney/Pro Se Party/Juvenile Officer (Print) I hereby certify that the above information is true and accurate: _________________________________________ Signature of Attorney/Pro Se Party/Juvenile Officer CCFC175 02/09 Address _________________ Date _____________________________ City _____________________ Bar Number State Zip Code ____________________ _______________ Phone Number Fax Number American LegalNet, Inc. www.FormsWorkFlow.com CASE TYPE Q3 Q4 Q5 QD QH QI QJ QK QL QM QN QO QP QR QS QX JA JB JC JE JI QA QB QE QQ CCFC175 02/09 CASE TYPE DESCRIPTION Domestic Relations IV-D Miscellaneous Domestic Relations IV-D Motion to Modify IV-D Paternity Change of Name Dissolution of Marriage without Children Dissolution of Marriage with Children Habeas Corpus – Domestic Legal Separation / Annulment / Separation Maintenance Modify Registration of Foreign Judgment Motion to Modify Paternity Registration of Foreign Judgment – Child Custody Registration of Foreign Judgment – Dissolution Miscellaneous Domestic Relations Family Access Motion Other Miscellaneous Action Juvenile Status Offense Delinquency Abuse and Neglect Termination of Parental Rights FC Ext Jurisdiction Juvenile Protection Orders Adult Abuse without Stalking Adult Abuse Stalking Child Protection Order Registration of Foreign Protection Order American LegalNet, Inc. www.FormsWorkFlow.com