CUSTODY INTAKE INFORMATION SHEET Information: 1.Child(ren)'s Child's name Birthdate Age Sex Person child lives with now Child's name Birthdate Age Sex Person child lives with now Child's name Birthdate Ag Sex Person child lives with now Child's name Birthdate Age Sex Person child lives with now 2.Mother: 3.Father: Last name, First, MI Number Street City State Last name, Birthdate Social Security # Street Apt. City Zip code MI. Number Apt. First name, State Birthdate Phone # Social Security # Phone # 4. Father: (Additional if necessary) How was Paternity Established? (Check One CSEA Last name, First, Number Street MI Affidavit Juvenile. Ct. Case Probate Never Done Case# or Paternity Registry #: Apt. 5. City Zip Code State Child(ren)'s Legal Custodian (other than parents): Zip code Last name, First name, Number, MI Street Birthdate Phone # Social Security # City How was Paternity established? (Circle One) CSEA Affidavit Probate Never done Juvenile Ct. Case State Zip Birthdate code Phone Number Case# or Central Paternity Registry #: YES NO 6. Have the above noted parents ever been married to each other? If YES, please specify the date of the marriage Are they Divorced? YES If YES, when was the divorce final 7. Applicant: Relationship to the child Last Name, Number City First name Street Apt. Checked By: Zip Code NO Staff Use Only: Birthdate Accepted By: Case Paternity Case # Family# Phone # American LegalNet, Inc. www.FormsWorkflow.com