Court of Common Pleas of Westmoreland County, Pennsylvania Domestic Relations Section 2 N Main St, 3rd Floor, Greensburg, PA 15601 Phone: 724-830-3200 Fax: 724-830-3256 For Office Use Only Complaint: New Reopen Child support Spousal support Modification Increase Decrease Terminate Reinstatement Plaintiff’s Name: _________________________ Defendant’s Name: ____________________ Docket Number: _________________________ PACSES Case Number: _______________ Other State ID Number: _________________________________________________________ Intake Information Questionnaire / Data Sheet Plaintiff / Caretaker’s Information (PERSON WHO WILL RECEIVE THE FUNDS.) Relationship to the Child / Children: Name: Last First Alias Address: Middle Mother’s Name (if not Plaintiff): (Street, Box #, Apt.) City County State Zip Plaintiff’s place of birth: SSN: City Physical Description: Sex: Male DOB: State Race Tattoos, Birthmarks, Scars: County PHONE: Eyes Hair Country Height Weight Email Address: Plaintiff’s: Mother’s Full Maiden Name: First Middle Maiden Father’s Name: 1 American LegalNet, Inc. www.FormsWorkFlow.com Plaintiff’s Attorney: Name: Address: Street City State Zip Plaintiff’s Employer: Name: Address: Net Pay: $ Street Per: City State Phone # ALL INSURANCE INFORMATION MUST BE FILLED OUT IN ITS ENTIRETY Plaintiff’s Medical Insurance Information: Name of Carrier: Address: Zip Policy #: Street City State Zip Phone # Plaintiff’s Marital Status with respect to the Defendant: Single: Married: Date of marriage: mm / dd/ yyyy Separated: Date separated: mm / dd / yyyy Place of Marriage: Address of Last Marital Domicile: Divorced: Date divorced: mm / dd / yyyy Place of Divorce: Street City State Zip Contact Person Other than Present Spouse: Name: Address: Relationship: Street City State Zip Phone # 2 American LegalNet, Inc. www.FormsWorkFlow.com Children’s Information Only this Defendant’s Child(ren): 1. Name: SSN: DOB: Mother’s Maiden Name: Has Paternity Been Established? Yes No County 2. Name: SSN: No Yes SSN: State DOB Mother’s Maiden Name: AGE: SEX: and Country of Birth AGE: SEX: Father’s Name: No Yes City County 4. Name: Hospital of Birth: State SSN: DOB: Mother’s Maiden Name: and Country of Birth AGE: SEX: Father’s Name: Yes City No Hospital of Birth: County 5. Name: State SSN: DOB: Mother’s Maiden Name: City and Country of Birth Hospital of Birth: County 3. Name: Has Paternity Been Established? State Father’s Name: City Has Paternity Been Established? Hospital of Birth: DOB: Mother’s Maiden Name: Has Paternity Been Established? SEX: Father’s Name: City Has Paternity Been Established? AGE: and Country of Birth AGE: SEX: Father’s Name: Yes No Hospital of Birth: County State and Country of Birth 3 American LegalNet, Inc. www.FormsWorkFlow.com Defendant’s Information: (PERSON WHO WILL PAY THE FUNDS.) Name: Last First Middle Alias Address: (Street, Box #, Apt.) City County State Zip Defendant’s place of birth: City SSN: County DOB: Physical Description: Sex: Male Race Tattoos, Birthmarks, Scars: State Country PHONE: Eyes Hair Height Weight Email Address: Defendant’s: Mother’s Full Maiden Name: Father’s Name: First Middle Maiden Defendant’s Attorney: Name: Address: Street City State Zip Defendant’s Employer: Name: Address: Net Pay: $ Per: Phone #: INSURANCE Defendant’s Medical Insurance Information: ALLENTIRETY INFORMATION MUST BE FILLED OUT IN ITS Name of Carrier: Address: Policy #: Phone #: 4 American LegalNet, Inc. www.FormsWorkFlow.com Contact Person Other than Present Spouse: Name: Relationship: Address: City Street State Zip Phone # Assistance / Existing support order information: Is (Are) the child(ren) a subject of any custody action? Yes No Are you receiving cash or medical assistance? Yes No Are you applying for either cash or medical assistance? Yes No Yes No If Yes, list child(ren)’s name(s): What is your Welfare Case Number? Do you have an existing support order: If yes what is the Case number? What county and state does the order exists in? County: State: What amount of spouse support do you receive per month? $ What amount of child support do you receive per month? $ What is the amount for the Family (Spouse and Child)? $ I verify that the statements in this document are true and correct to the best of my knowledge. Also, I understand that any false statement is subject to penalty according to 18 Pa. C. S. section 4904 relating to unsworn falsification to authorities. Date ____________________________________________ Plaintiff/ Caretaker Signature 5 American LegalNet, Inc. www.FormsWorkFlow.com If you desire to Modify (Increase or Decrease) your support order, please provide a reason in the space below. There is a $25.00 filing fee for all modifications. 6 American LegalNet, Inc. www.FormsWorkFlow.com