Parent/Custodian Information Sheet and Jurisdiction Screening - Fairfield County Juvenile Division

Child or Children's Names Case Number Mother or Custodian Party Name Mother or Custodian Birthdate Mother or Custodian Current Street Address Mother or Custodian City Mother or Custodian State Mother or Custodian Zip Mother or Custodian Phone Mother or Custodian Email Address Father or Custodian Party Name Father or Custodian Birthdate Father or Custodian Current Street Address Father or Custodian City Father or Custodian State Father or Custodian Zip Father or Custodian Phone Father or Custodian Email Address Child Contact Information Party Name Child Contact Information Birthdate Child Contact Information Current Street Address Child Contact Information City Child Contact Information State Child Contact Information Zip Child Contact Information Phone Child Contact Information Email Address Second Child Contact Information Party Name Second Child Contact Information Birthdate Second Child Contact Information Current Street Address Second Child Contact Information City Second Child Contact Information State Second Child Contact Information Zip Second Child Contact Information Phone Second Child Contact Information Email Address Other Parties Contact Information Party Name Other Parties Contact Information Birthdate Other Parties Contact Information Current Street Address Other Parties Contact Information City Other Parties Contact Information State Other Parties Contact Information Zip Other Parties Contact Information Phone Other Parties Contact Information Email Address Court Name and Location Type of Order Protected Party Order Issued Against Signature of person completing form Date Printed Name

Child's Name - First Middle Last Child's Birthdate Child's Mother's Name Child's Father's Name

Are the child's parents now married?

Are the child's parents now married? Yes Are the child's parents now married? No

Have the child's parents ever been married to each other?

Have the child's parents ever been married to each other? Yes Have the child's parents ever been married to each other? No

Is there a custody or child support order in any court for this child or child's siblings of the same parents?

Is there a custody or child support order in any court for this child or child's siblings of the same parents? Yes Is there a custody or child support order in any court for this child or child's siblings of the same parents? No

Is there a pending divorce, dissolution, annulment, or legal separation between the child's parents?

Is there a pending divorce, dissolution, annulment, or legal separation between the child's parents? Yes Is there a pending divorce, dissolution, annulment, or legal separation between the child's parents? No

If there is custody or child support order for the child's siblings, provide sibling names Additional space to provide siblings' names Court, County, and State that issued the custody, visitation, or child support order Additional space to provide Court, County, and State that issued the custody, visitation, or child support order Case Number

Is there a child support order?

Is there a child support order? Yes Is there a child support order? No

Is there a custody order?

Is there a custody order? Yes Is there a custody order? No

What County and State do you and the child presently reside in? Signature of person completing form Date Printed Name