| Date:_________________________ |
DMS File #_________________________ |
| Cause:_________________________ |
Judge/Master _______________________________________ |
| Style: _________________________ |
Referred by: ________________________________________ |
| Pending Divorce_____ |
Modification_____ |
Never Married_____ |
| Regarding: _____ Conservatorship |
_____ Access |
_____ Child Support |
_____ Property |
| _____ Other, Please specify:_______________________________________________________________ |
| Children |
Birthdate |
| _____________________________________________________________ |
_______________________ |
| _____________________________________________________________ |
_______________________ |
| _____________________________________________________________ |
_______________________ |
| Note: If AG, CPS, Ad Litem, or others are involved in this case it is your reponsibility to provide DMS with the names, addresses and phone numbers for each party. (Please use additional paper if needed. |
| IP (Petitioner) |
RP (Respondent) |
| Name ________________________________________ |
Name ________________________________________ |
| Address ______________________________________ |
Address ______________________________________ |
| City _______________________ Zip _____________ |
City _______________________ Zip _____________ |
| Phone (H) _______________ (W)________________ |
Phone (H) _______________ (W)_________________ |
| Relationship to child___________________________ |
Relationship to child___________________________ |
| Annual Income _______________________________ |
Annual Income _______________________________ |
If married, combined liquid assets of the marriage:
______________________________________________
|
If married, combined liquid assets of the marriage:
______________________________________________ |
*Is a bilingual mediator necessary? ___Yes___No
(DMS will try to honor your request) |
*Is a bilingual mediator necessary? ___Yes___No
(DMS will try to honor your request) |
| Attorney will attend ___Yes___No |
Attorney will attend ___Yes___No |
| IP Attorney |
RP Attorney |
| Name ________________________________________ |
Name ________________________________________ |
| Address ______________________________________ |
Address ______________________________________ |
| City _______________________ Zip _____________ |
City _______________________ Zip _____________ |
| Phone _________________ Fax ___________________ |
Phone __________________ Fax__________________ |
