JUVENILE COURT OF MEMPHIS AND SHELBY COUNTY, TENNESSEE PROTECTIVE SERVICES INFORMATION SHEET FOR ATTORNEYS AND AGENCY REPRESENTATIVES Name of Attorney: _____________________________ Name of Agency: _______________________________ Address: __________________________________ Phone: ___________________ Zip Code: ______________ Name and address of legal custodian: ___________________________________________________________ ___________________________________________________________________ Phone: _________________ Name and address of person(s) with whom child(ren) is/are residing: ___________________________________ __________________________________________________________________ Phone: _________________ Name and address of person(s) requesting custody: ________________________________________________ ___________________________________________________________________ Phone: _________________ Name of Child(ren) Date of Birth School SSN# Grade Sex/Race __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Full names and addresses of parents of the above listed child(ren) Mother: _________________________________ Address: _____________________ SSN#: __________________ Father: _________________________________ Address: _____________________ SSN#: __________________ Have any of these child(ren) been to Juvenile Court before? Were the parents married? Yes Yes No No Do these child(ren) receive welfare? Yes No Does anyone receive child support for these children? Yes No List all FULL names of children of the mother. ___________________________________________ __________________________________________ ___________________________________________ __________________________________________ ___________________________________________ __________________________________________ JC-103B American LegalNet, Inc. www.USCourtForms.com