Pennsylvania > Local County > Philadelphia > Family
Domestic Relations Information Sheet - Pennsylvania
| Domestic Relations Information Sheet Form. This is a Pennsylvania form and can be used in Family Philadelphia Local County . |
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FIRST JUDICIAL DISTRICT OF PENNSYLVANIA ยท PHILADELPHIA FAMILY COURT DOMESTIC RELATIONS INFORMATION SHEET (Parties in domestic relations cases must complete this form at every appearance) INSTRUCTIONS Print clearly, and provide all of the information in each box; if anything does not apply to you, write N/A in the box. Use the back page of the form if you need additional space to provide a complete answer. INFORMATION FOR THE DOMESTIC RELATIONS CASE YOU ARE APPEARING FOR TODAY 1. Docket No. 2. PACSES No. (support cases only) 3. In this case you are the: Plaintiff/Petitioner Defendant/Respondent 4. Check each type of case you have with the other party in this case (If a case is not in Philadelphia, note the city and state) Protection from Abuse (PFA) Support Custody Divorce Is a PFA order in effect? No Yes If yes, specify the person(s) protected under the order: 5. Does the Philadelphia Department of Human Services (DHS) have a case(s) involving the child(ren) in this case? No Yes If yes, specify the child(ren) and the status of the DHS case(s): 6. Do you have reason to fear being in the same room with the other party in this case? No Yes* (see below) *IMPORTANT: Before you enter the proceeding be sure to explain the circumstances to the court staff member who checked you in DEMOGRAPHIC AND CONTACT INFORMATION 8. Date of Birth 9. Social Security No. _ _ 7. Name (F/M/L) 10. Home Address ( 12. Home Tel. No. ( ) check if new) Apt./Unit No. City State 15. Hght 16. Wght Zip Code 11.Education Level 13. Mobile Tel. No. ( ) 14. Email Address INCOME AND EMPLOYMENT 17.EyeCol 18.Gender 19.Race 20. Employer Name ( check if new) Address City State Zip Code Tel. No. ( 21. Gross (pre-tax) Income ) $ None Cash 24. Do No 23. Do you have health insurance? No Yes (if yes, provide the following) Type(s) of coverage (e.g, medical, dental, etc.) per Name of Insurance Company Policy No. 22.Welfare benefits you receive: Medical Food Stamps Yes (If yes, complete below): Address City Name(s) of person(s) covered under policy: 25. Any professional or business licenses? 26. Driver License None No Yes (If yes, complete below): Standard DL Commercial DL License Type Number Issuing State Number Issuing State you have any pending legal claims or lawsuits? State Zip Code Attorney's Name 27. Do you have any other employment or income from source(s) that you did not provide above? I verify that I have no employment or income other than I provided above Yes (provide the amount and sources of any and all income that is not listed above, use the back of this form if you need additional space) Amount of income $ per Income Source Address City State Zip Code Telephone No. VERIFICATION 28. I verify that the statements made herein are true and correct. I understand that false statements herein are subject to contempt sanctions in my domestic relations case(s) and the penalties of 18 Pa. C.S.4904, relating to unsworn falsification to authorities. _______________________________________________________________________ __________________________________ Signature 09-711 (Rev. 4/2011) Date American LegalNet, Inc. www.FormsWorkFlow.com Write the number of the question next to the additional information you are providing in response ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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