CIVIL CASE FILING STATEMENT ( “IN THE MATTER OF” Cases) IN THE MATTER OF: ________________________________________________________________ _________________________________________________________________________ Please check the participant role you are filing on behalf Complete a form for each additional Participant Trust Estate Adoption/Termination of Parental Rights Trustee Birth Name Trustor Adoptive parent Name of Trust Birth Mother Other ___________________________ Birth Father Other ____________________________ Involuntary Committal Mental Illness Alleged Alcoholic/Drug abuser Alleged Mentally Ill Person Petitioner Petitioner Other ___________________________ Other ___________________________ Civil Probate Petitioner Deceased Other ____________________________ Personal Representative Other ___________________________ Guardianship/Conservatorship Minor Person alleged to need protection Guardian Ad Litem Other ____________________________ Name: ____________________________________ ____________________ _______ ______ Last First Middle Suffix Address:_______________________________________________________________________ City: ________________________________________ State: __________ Zip: _____________ Date of Birth: _____ ____ ______ mm dd yyyy Social Security #: _____ - ____ - ______ and/or Drivers license #_______________ State ____ Employer ID (if Petitioner is a business or other entity) _____________________________ Attorney: __________________________________ ______________________ ______________ Last First Middle Address: ___________________________________________ Phone: _______________________ City: ___________________________________________ State: ___________ Zip: ___________ Revised 3-05 UJS Form 233