Fill and Sign the Nevada Case Form

Case No.       Dept. No.       In the Family Division       Judicial District Court, State of Nevada,       County       Plaintiff, PERSONAL CASE INFORMATION (UCCJA) v.       Defendant. This Document is submitted by: Plaintiff Defendant WIFE HUSBAND Name:       Name:       Present Home Address: Present Home Address:                         Place of Employment Address Place 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/Age Resides With/How Long                                                       Children: Born Prior To Marriage/Other Dependents Name Date of Birth/Age Resides 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 THIS PROCEEDING. THE NAMES AND PLACES WHERE EACH CHILD HAS LIVED WITHIN THE LAST FIVE (5) YEARS AND THE NAME(S) AND RELATIONSHIP TO THE CHILD OF EACH PERSON WITH WHOM THE CHILD HAS LIVED DURING THAT TIME ARE: 1. Child’s Full Name:       Lives with: Mother Father Both Other *Current Address:       Date: From       To Present ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Second Address:       Date: From       To       SEE ADDITIONAL PAGE YES NO 2. Child’s Full Name:       Lives with: Mother Father Both Other *Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Second Address:       Date: From       To       SEE ADDITIONAL PAGE YES NO Page 2 of 5 3 . Child’s Full Name:       Lives with: Mother Father Both Other *Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Second Address:       Date: From       To       SEE ADDITIONAL PAGE YES NO 4. Child’s Full Name:       Lives with: Mother Father Both Other *Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *Prior to Current Address:       Date: From       To       ---------------------------------------------------------------------------------------------------------------------------------- Lives with: Mother Father Both Other *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.       THE FOLLOWING CASES INVOLVING EITHER THE PLAINTIFF AND DEFENDANT, AND/OR THE CHILD(REN) ARE PRESENTLY PENDING IN COURT OR WERE FILED WITH THE COURT IN THE LAST TEN (10) YEARS: 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 Declarant Signature of Attorney SUBSCRIBED and SWORN to before me this       day of       , 20 NOTARY PUBLIC Page 5 of 5