Fill and Sign the Respondents Civil Case Information Statement Sca Fc 114

SCA-FC-103: Petitioner's Civil Case Information Statement-Domestic Relations Cases Review Date: 09/2014; Revision Date: 09/2014; WVSCA Approved: 06/17/2014 Page 1 of 2 IN THE FAMILY COURT OF COUNTY, WEST VIRGINIA IN RE: The Marriage / Children Of: Case No. Judge: Petitioner (First/Middle/Last) . and Respondent (First/Middle/Last) , PETITIONER'S CIVIL CASE INFORMATION STATEMENT DOMESTIC RELATIONS CASES PETITIONER'S IDENTIFYING INFORMATION IMPORTANT NOTICE Street Address City / State / Zip Code ( ) - Phone Number Male / Female - - Social Security Number / / Date of Birth Race: American Indian/Alaskan Native Asian or Pacific Islander Unknown Hispanic Black White Check this box if you wish to keep the information in this box CONFIDENTIAL because you fear for your safety and/or the safety of your children. If the box above is checked, this page is sealed in the file and NOT TRANSMITTED with the Petition and Summons. You must complete the form, Affidavit To Withhold Identifying Information, and file it at the Circuit Clerk's Office. YES NO Do you or any of your clients or witnesses in this case require special accommodations due to a disability? IF YES, SPECIFY: Wheelchair accessible hearing room and other facilities; Interpreter or other auxiliary aid for the hearing impaired; Reader or other auxiliary aid for the visually impaired; Spokesperson or other auxiliary aid for the speech impaired; Other: Original and copies of petition enclosed/attached. List all minor children affected by this action: Name Date of Birth Social Security Number / / - - / / - - / / - - / / - - SCA-FC-103: Petitioner's Civil Case Information Statement-Domestic Relations Cases Review Date: 09/2014; Revision Date: 09/2014; WVSCA Approved: 06/17/2014 Page 2 of 2 PETITIONER: RESPONDENT:Case No. Days To Answer: Type of Service: 1. RESPONDENT'S IDENTIFYING INFORMATION 2. TYPE OF CASE RELIEF (Check All That Apply) Street Address City / State / Zip Code ( ) - Phone Number Male / Female - - Social Security Number / / Date of Birth Race: American Indian/Alaskan Native Asian or Pacific Islander Unknown Hispanic Black White Divorce Without Children Divorce With Children Grandparent Visitation Annulment Separate Maintenance Child Support Only Child Custody Without Divorce Paternity Modification Contempt Infant Guardianship Other (specify) : 3. YES NO Is either party seeking child support or alimony? 4. YES NO Is a Domestic Violence Protective Order in effect now? 5. YES NO Is there an active Child Protective Services (CPS) investigation of the children or was an investigation conducted in the last year prior to filing this action? 6. I am proceeding without an attorney. OR I have an attorney. (Complete attorney information below.) Attorney Name: Firm: Address: Telephone: ( ) - Dated: Signature