Fill and Sign the List of American Federal Politicians Convicted of Crimes Form

Case No. Dept. No. In t h e F am ily D iv is io n J u dic ia l D is tr ic t C ourt, S ta te o f N ev ad a, C ounty Plaintiff, PERSONAL CASE INFORMATION (UCCJA) v. Defendant. This Document is submitted by: Plaintiff Defendant WIFE HUSBANDName: Name: Present Home Address: Present Home Address: Place of Employment AddressPlace of Employment Address Age: SS# Age: SS# Education: Education: Degree/Major Degree/Major Date Obtained: Date Obtained: Parties were married on: Separated on: Children: Born To This Marriage Name Date of Birth/AgeResides With/How Long Children: Born Prior To Marriage/Other Dependents Name Date of Birth/AgeResides With/How Long Page 1 of 5 JUD-114 Case No. UCCJA INFORMATION Dept. No. THERE IS/ARE NUMBER OF CHILD(REN) OF THE PARTIES SUBJECT TO T H IS P RO CEED IN G. T H E N AM ES A ND P L A CES W HER E E A CH C H IL D H AS L IV ED W IT H IN THE L AST F IV E ( 5 ) Y EA RS A ND T H E N AM E(S ) A ND R ELA TIO NSH IP T O T H E C H IL D O F E A CH PE R SO N WITH WHOM THE CHILD HAS LIVED DURING THAT TIME ARE: 1. Child’s Full Name: Lives with: Mother FatherBoth Other *Current Address: Date: From To Present----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Second Address: Date: From To SEE ADDITIONAL PAGE YES NO 2. Child’s Full Name: Lives with: Mother FatherBothOther*Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Second Address: Date: From To SEE ADDITIONAL PAGE YES NO Page 2 of 5 3. Child’s Full Name: Lives with: Mother FatherBothOther*Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Second Address: Date: From To SEE ADDITIONAL PAGE YES NO 4. Child’s Full Name: Lives with: Mother FatherBothOther*Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Current Address: Date: From To ----------------------------------------------------------------------------------------------------------------------------------Lives with: Mother FatherBothOther*Prior to Second Address: Date: From To SEE ADDITIONAL PAGE YES NO ************************************************************************************************************1. Have you participated as a party witness or in any other capacity in any litigation concerning custody of any children subject to this proceeding? YES NO 2. Do you have any information of any custody proceeding concerning the child(ren) pending in a court of this or any state? YES NO Page 3 of 5 3. Do you know of any person a party to the proceedings who has physical custody of the child(ren) or claims to have custody or visitation rights respect to the child(ren)? YES NO IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE PLEASE EXPLAIN. Page 4 of 5 Case No. PRIOR/PENDING ACTIONS Dept. No. T H E F O LLO W IN G C A SE S I N VOLV IN G E IT H ER T H E P L A IN TIF F A ND D EFE N DANT, A ND/O R TH E C H IL D (R EN ) A RE P R ESE N TLY P E N DIN G I N C O URT O R W ER E F IL ED W IT H T H E C O URT I N THE L A ST T EN ( 1 0) Y EA RS:1. Name of Court: Location of Court (Count & State): Parties Involved: Case Number Type of Action: 2. Name of Court: Location of Court (Count & State): Parties Involved: Case Number Type of Action: 3. Name of Court: Location of Court (Count & State): Parties Involved: Case Number Type of Action: THAT I DO SWEAR UNDER THE PENALTY OF PERJURY THAT THE ASSERTIONS CONTAINED IN THIS CASE INFORMATION STATEMENT ARE TRUE. Signature of DeclarantSignature of Attorney SUBSCRIBED and SWORN to before methis day of , 20 NOTARY PUBLIC Page 5 of 5