PATERNITY INTAKE FORM
Date
/
Month
/
Day
Year
Date
Attorney (Office use only)
MWY
BEB
ZMP
EMC
Your Information
Name
*
First Name
Last Name
Address
*
City
*
State
*
ZIP
*
County of Residence
*
Cell Phone Number
*
Format: (000) 000-0000.
Work
Other
Email Address
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Social Security Number
*
Employer
Employer Address
Average Weekly Income
Hourly
Salary
Other Parent’s Information
Name
*
First Name
Last Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Format: (000) 000-0000.
Work
Other
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Employer
Employer’s Address
Employer’s Address
Average Weekly Income
Hourly
Salary
Where to serve Other Party
Work
Home
Children
Rows
Name
Date of Birth
SSN
Gender
Highest Education Level
Child 1
Child 2
Child 3
Child 4
Child 5
Has a Petition to Establish Paternity already been filed?
No
Yes
If Yes, What County?
If No, 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 briefly describe any current parenting time arrangements
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