Intake Information Questionnaire-Data Sheet

Court of Common Pleas of Westmoreland County, Pennsylvania Domestic Relations Section 2 N. Main St., Suite 302, Greensburg, Pa. 15601 Phone: 724-830-3200 For Office Use Only Complaint: New Reopen Decrease Child support Terminate Spousal support Reinstatement Fax: 724-830-3256 Modification Increase Plaintiff's Name: _________________________ Defendant's Name: ____________________ Docket Number: _________________________ PACSES Case Number: _______________ Other State ID Number: _________________________________________________________ Intake Information Questionnaire / Data Sheet Plaintiff / Caretaker's Information (PERSON WHO WILL RECEIVE THE FUNDS.) Relationship to the Child / Children: Name: Last First Middle Alias Address: (Street, Box #, Apt.) Mother's Name (if not Plaintiff): City County State Zip Plaintiff's place of birth: City State County Country SSN: Physical Description: Sex: DOB: PHONE: Race Eyes Hair Height Weight Tattoos, Birthmarks, Scars: Email Address: Plaintiff's: Mother's Full Maiden Name: First Middle Maiden Father's Name: 1 American LegalNet, Inc. www.FormsWorkFlow.com Plaintiff's Attorney: Name: Address: Street City State Zip Plaintiff's Employer: Name: Address: Street City State Zip Phone # Net Pay: $ Per: Plaintiff's Medical Insurance Information: Name of Carrier: Address: Street City State Zip Phone # Policy #: Plaintiff's Marital Status with respect to the Defendant: Single: Married: Separated: Divorced: Date of marriage: mm / dd/ yyyy Place of Marriage: Date separated: mm / dd / yyyy Date divorced: mm / dd / yyyy Place of Divorce: Address of Last Marital Domicile: Street City State Zip Contact Person Other than Present Spouse: Name: Address: Street City State Zip Phone # Relationship: 2 American LegalNet, Inc. www.FormsWorkFlow.com Children's Information Only this Defendant's Child(ren): 1. Name: Mother's Maiden Name: Has Paternity Been Established? Yes No SSN: DOB: Father's Name: Hospital of Birth: AGE: SEX: City County State and Country of Birth 2. Name: Mother's Maiden Name: Has Paternity Been Established? Yes SSN: DOB: Father's Name: No Hospital of Birth: AGE: SEX: City County State and Country of Birth 3. Name: Mother's Maiden Name: Has Paternity Been Established? Yes SSN: DOB Father's Name: No Hospital of Birth: AGE: SEX: City County State and Country of Birth 4. Name: Mother's Maiden Name: Has Paternity Been Established? City SSN: DOB: Father's Name: AGE: SEX: Yes County No Hospital of Birth: State and Country of Birth 5. Name: Mother's Maiden Name: Has Paternity Been Established? Yes SSN: DOB: Father's Name: No Hospital of Birth: AGE: SEX: City County State and Country of Birth 3 American LegalNet, Inc. www.FormsWorkFlow.com Defendant's Information: (PERSON WHO WILL PAY THE FUNDS.) Name: Last First Middle Alias Address: (Street, Box #, Apt.) City County State Zip Defendant's place of birth: City County State Country SSN: Physical Description: Sex: DOB: PHONE: Race Eyes Hair Height Weight Tattoos, Birthmarks, Scars: Email Address: Defendant's: Mother's Full Maiden Name: First Middle Maiden Father's Name: Defendant's Attorney: Name: Address: Street City State Zip Defendant's Employer: Name: Address: Defendant's Medical Insurance Information: Name of Carrier: Address: Policy #: Phone #: Net Pay: $ Phone #: Per: 4 American LegalNet, Inc. www.FormsWorkFlow.com Contact Person Other than Present Spouse: Name: Address: Street City State Zip Phone # Relationship: Assistance / Existing support order information: Is (Are) the child(ren) a subject of any custody action? If Yes, list child(ren)'s name(s): Yes No Are you receiving cash or medical assistance? Are you applying for either cash or medical assistance? What is your Welfare Case Number? Do you have an existing support order: If yes what is the Case number? What county and state does the order exists in? County: State: Yes Yes No No Yes No What amount of spouse support do you receive per month? $ What amount of child support do you receive per month? What is the amount for the Family (Spouse and Child)? $ $ I verify that the statements in this document are true and correct to the best of my knowledge. Also, I understand that any false statement is subject to penalty according to 18 Pa. C. S. section 4904 relating to unsworn falsification to authorities. Date ____________________________________________ Plaintiff/ Caretaker Signature 5 American LegalNet, Inc. www.FormsWorkFlow.com If you desire to Modify (Increase or Decrease) your support order, please provide a reason in the space below. There is a $25.00 filing fee for all modifications. 6 American LegalNet, Inc. www.FormsWorkFlow.com