COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.FRD-10 (2/00)PARENT QUESTIONNAIREFOR COURT USE ONLY & INFORMATION SHEETCASE NO. JUDGE:P: D: DATE RECEIVED: A. PERSONAL:Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)NameStreet addressCityStateZip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Home phoneWork phoneTHE PEOPLE OF THE STATE OF NEW YORK TOPlease list highest grade completed and/or any specific training you may have received:Name and address of current employer:Current work hours and days:Starting date:GREETINGS:List all other jobs held during the past 3 years, beginning with the most recent, Including dates of employment:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour Attorney's NamePhoneFaxYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Business addressCityZipState, one of the Justices of theCourt in Witness, Honorableday of, 20 County,B. MARITAL HISTORY: What have been the major problems in the marriage?(Attorney must sign above and type name below)YesNoWere there any previous separations? Who initiated the separation? Who left the home? Have you filed for divorce before? If so, where?Attorney(s) forWifeHusbandWifeHusbandYesNoOffice and P.O. AddressDateDateTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comPage 1 of 6COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.C. CUSTODY:NoYesCalendar No.NoYesJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)NoYesNoYes Is there a Court Order for custody? Are you requesting Shared Parenting? Have you filed a Shared Parenting plan? Have you filed for custody?What are your feelings with regard to your spouse having custody?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D. MEDIATION: **pleasereviewtheenclosedmediationbrochure** Parents are encouraged to work together to make the best possible parenting arrangement for their children. Mediation provides a structured, open discussion of many options, a means for the parents to retain control of the outcome of their divorce, and is generally quicker, more satisfying, and less expensive than litigation.THE PEOPLE OF THE STATE OF NEW YORK TONoYes Are you interested in having the option to mediate with your spouse?GREETINGS:If you have questions about whether or not mediation would be appropriate for your case, please call 225-4191. E. FINANCES and CHILD SUPPORT:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofAre you on any form of government assistance?NoYesIf so, what kind?o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomWas bankruptcy filed during the marriage?NoIf so, who filed?YesPlace & date of filing; case number; other relevant information:Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Is there a court order for child support for children of this marriage?If so, who pays the support:YesNo, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Is child support being paid without a court order?Your spouseYouYesNoWhat is the amount per child, and per week or per month?(Attorney must sign above and type name below)Is this amount paid or received on a regular basis?YesNoAttorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comPage 2 of 6COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.F. HEALTH:Calendar No.PoorFairGoodExcellentAre there any physical problems? Please describe:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)YouYour spouseYou:NoYes Are you or your spouse currently under the care of a physician, psychiatrist, or psychologist?If so, please provide the following information:NoYesYour spouse:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Their namePhone #AddressTHE PEOPLE OF THE STATE OF NEW YORK TOIf you are currently on any kind of prescription drug, please list, and give the name of the doctor who prescribed the medication:GREETINGS:You:NoYes Have you or your spouse ever been institutionalized for any reason?If so, please provide the following information:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableNoYesYour spouse:,located at County ofDoctor's namePhone #Institution name and addresso'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomDo you drink alcohol?NoYesIf yes, how often?Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Does your spouse?NoYesIf yes, how often?Have you ever abused drugs?NoYesIf yes, please give full explanation:, one of the Justices of theHas your spouse ever abused drugs?NoYesIf yes, please give full explanation:Court in Witness, Honorableday of, 20 County,G. HOME IN WHICH YOU CURRENTLY RESIDE:(Attorney must sign above and type name below)Number of bedrooms:Type of dwelling:Names of other persons living in the home:Relationship:Attorney(s) forOffice and P.O. Addres
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