Custody/PT/CS Modification Intake Form
Date
/
Month
/
Day
Year
Date
Attorney (Office use only)
MWY
BEB
ZMP
EMC
Type of Case
Modification of paternity order
Modification of divorce order
Your Information
Name
*
First Name
Last Name
Address
*
City
*
State
*
ZIP
*
County of Residence
*
Cell Phone Number
*
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Other Phone Number
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
Social Security Number (Last 4)
Employer
Employer Address
Average Weekly Income
Wages paid:
Hourly
Salary
Other Party’s Information
Name
*
First Name
Last Name
Address
City
State
ZIP
County of Residence
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Other Phone Number
Format: (000) 000-0000.
Date of Birth
Social Security Number (Last 4)
Employer
Employer’s Address
Employer’s Address
Average Weekly Income
Hourly
Salary
Where should we serve the other party?
At Home
At Work
Case Information
The existing court order is from a:
Divorce
Paternity Action
Was the original case filed in Indiana?
Yes
No
If Yes, in what county was the case been filed?
If No, in what state and county was the case been filed?
Does the other party have an attorney?
Yes
No
If Yes, what is the attorney’s name?
Children
Type a question
Rows
Name
DOB
SSN
Gender
Level of Education
Child 1
Child 2
Child 3
Child 4
Child 5
Which parent has custody of the children?
Mother
Father
In what County and State do the children currently reside?
Have they resided in their current state and county for the preceding six months?
No
Yes
If No, in what County and State did they previously reside?
Please describe the current parenting time arrangements.
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