GUARDIANSHIP & THIRD-PARTY CUSTODY INTAKE FORM
Date
/
Month
/
Day
Year
Date
Attorney (Office Use Only)
MWY
BEB
ZMP
EMC
Type of Case
Establish Guardianship
Dissolve Guardianship
Third-Party Custody
Are you the:
Mother
Father
Guardian/Intervenor
Mother’s Information
Name
*
First Name
Last Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Work
_ Other
Email Address
example@example.com
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Social Security Number
Hourly
Salary
Employer
Employer Address
Average Weekly Income
Father’s Information
Name
*
First Name
Last Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Work
Other
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Employer
Employer’s Address
Employer’s Address
Average Weekly Income
Average Weekly Income
Hourly
Salary
Serve Relevant party/parties at:
Work
Home
Guardian/Intervenor’s Information
Name
*
First Name
Last Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Work
Other
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Social Security Number
Hourly
Salary
Employer
Employer’s Address
Employer’s Address
Average Weekly Income
Case Information
For Third-Party Custody, is it related to a divorce or a paternity case?
Divorce
Paternity Case
Was the original case filed in Indiana?
Yes
No
If Yes, in what county was it filed?
If No, in what state and county was it filed?
Attorney’s name
Does Other Party have an attorney?
No
Yes
Children
Name
Date of Birth
SSN
Gender
Highest Education Level
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?
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