JUVENILE COURT OF MEMPHIS AND SHELBY COUNTY, TENNESSEE CHILD SUPPORT SERVICES DIVISION COMPLAINT DATA SHEET Date _____________________________________ PA NPA OTHER LEGITIMATION MODIFICATION NONSUPPORT PATERNITY SUPPORT PETITION Record Check _____________________________ ORIGINAL JURISDICTION: JUVENILE COURT CIRCUIT COURT CHANCERY COURT FOREIGN ORDER CONFERENCE COURT EXEMPT NON-EXEMPT DEFENDANT Name: ________________________________________ Sex/Race: __________ DOB: _______________ Height: _________ Weight: _________ Eyes: _________ Hair: _________ SSN: ___________________ Marital Status: ___________ Primary Occupation: ______________________________________________ Total Number of Children Under Eighteen (18) Supported by Defendant: ______________________________ Address: ________________________________________________________________________________ Street City Employer: _________________________ Zip Code Address: _____________________________________________ Home Phone: ______________________________ Employer's Phone: ______________________________ Parent's/Relatives Address (if applicable): ______________________________________________________ PETITIONER Name: ________________________________________ Sex/Race: __________ DOB: _______________ Height: _________ Weight: _________ Eyes: _________ Hair: _________ SSN: _______________________ IV-D Number: _______________________________ TANF Number: __________________________________ Address: ________________________________________________________________________________ Street City Employer: _________________________ Zip Code Address: _____________________________________________ Home Phone: ______________________________ Employer's Phone: ______________________________ Group Insurance Number: ___________________________________________________________________ Parent's/Relatives Address (if applicable): ______________________________________________________ Marriage Record: __________________________________________________________________________ List Date Current Status of Minor Children (under this case): ________________________________________________________ _________________________________________________________________________________________ Additional Information: ______________________________________________________________________ ________________________________________________________________________________________ Modification of previous order of _______________________________ under RD ____________________ to ______________________________________________________________________________________ That surname(s): be changed to that of natural father; remain the same. _____________________________________________ Mediator 6/15/03 JC–195 American LegalNet, Inc. www.USCourtForms.com