Fill and Sign the Louisiana Domestic Form

Appendix (3). Fact Sheet _____ JUDICIAL DISTRICT COURT PARISH OF JEFFERSON STATE OF LOUISIANA FACT SHEET DOMESTIC DOMESTIC RELATIONS RELATIONS SECTIONS 1. GENERAL INFORMATION Case Name: ____________________ Case Number: __________ Date Filed: __________ Matter Set for Hearing or Trial: ____________________ Attorney's Name: ______________________________ Attorney's Phone Number: _______________ Attorney's Address: ________________________________________ Client's Name: ______________________________ Client's Address: ________________________________________ Client's Age: _____ and Date of Birth: __________ Client's Social Security No.: _______________ 2. IF A RULE FOR ALIMONY AND/OR CHILD SUPPORT IS SET FOR HEARING, ANSWER FOLLOWING: Name and Address of Employer: ________________________________________ Your Position Held: ______________________________ Length of Employment: _______________ If not employed, are you able to work? ____________________ Yes No If you are not able to work indicate why __________________________________ If you are not able to work indicate how long it will take to acquire the appropriate education, training to enable you to get employment. Children: Yes No Date(s) of Birth(s): _______________ Age(s): __________ School(s): ________________________________________ Grade(s): __________ 3. IF A RULE TO INCREASE OR DECREASE ALIMONY AND/OR CHILD SUPPORT IS SET FOR HEARING, ANSWER THE FOLLOWING: Date of Last Support Order: ______________________________ Amount of Support Ordered: $ _________ Alimony: $ _________ Child Support: $ _________ Changes of Circumstances Alleged: A. ________________________________________ B. ________________________________________ C. ________________________________________ D. ________________________________________ 4. IF A RULE FOR CONTEMPT IS SET FOR HEARING, ANSWER THE FOLLOWING: Date of Last Support Order: __________ Amount of Support Ordered: $ _________ Alimony: $ _________ Child Support: $ _________ Date Last Payment was Made: $ _________ Amount in Arrears: $ _________ Dates of any previous Judgments for Contempt: ____________________________ 5. IF A RULE FOR CUSTODY IS SET FOR HEARING, ANSWER THE FOLLOWING: Number of Children: __________ Children: Name(s): ______________________________ Date(s) of Birth(s): __________ Age(s): __________ School(s): ________________________________________ Grade(s): __________ Religion: ____________________ If you work, have you arranged for day care of the children? Yes No If Yes, who will care for the children? Name: ______________________________ Relationship: ____________________ Address: _____________________________________________________________ SWORN TO AND SUBSCRIBED Before me, Notary Public, this _____ day of _______________ , 20 _____ . Notary Public ________ ________________________________________ Plaintiff/Defendant Address