Print Fairfax County Circuit Court DOMESTIC CASE COVERSHEET COMPLAINANT Name: Street: Name: Street: DEFENDANT Clear Form City: State: Zip City: Phone Number: ( ) State: Zip: Phone Number: ( ) Complainant Proceeding Without Counsel. ATTORNEYS COMPLAINANT ATTORNEY BAR ID: FIRM: DEFENSE ATTORNEY ANSWER DATE: CROSS-BILL DATE: BAR ID: FIRM: Name: Street: Name: Street: City: Phone Number: ( ) State: Zip City: Phone Number: E-mail Address: ( State: ) Zip E-mail Address: DATE OF SEPARATION: __________________________________ (Check all that apply): TOTALLY UNCONTESTED (custody, support and property issues resolved OR no custody, property or support issues) DIVORCE CONTESTED PROPERTY OR SUPPORT ISSUES CONTESTED CUSTODY ISSUES Please reflect original Chancery case Number CH___________________________ OTHER: ANNULMENT SEPARATE MAINTENANCE ORE TENUS (planning to file a Request for Ore Tenus hearing) DEPOSITION RE-OPEN ­ DOMESTIC ISSUES Custody Visitation Support Show Cause Other__________________ REQUESTED SERVICE: SERVICE DATE/TYPE SHERIFF SPECIAL PROCESS SERVER ACCEPTANCE PUBLICATION WAIVER NO SERVICE AT THIS TIME CCR H-42 Revised-August 2012 American LegalNet, Inc. www.FormsWorkFlow.com