Free CIVIL CASE INFORMATION STATEMENT (SCA-DV-FC-M-1200) - West Virginia

CIVIL CASE INFORMATION STATEMENT DOMESTIC VIOLENCE CASES
IN THE MAGISTRATE/FAMILY COURT OF COUNTY, WEST VIRGINIA Magistrate Court Case No.: Family Court Civil Action No.: Family Court Judge

CASE STYLE: IN RE
THE DOMESTIC VIOLENCE CIVIL PROCEEDING OF:

PETITIONER (person filling out this form)
Please keep my address and the addresses of other protected persons confidential because I fear for my/their safety. I do not want my order in the National Domestic Violence Registry. (Checking this box may hinder enforcement of a protective order)

First

Middle

Last

Street Address (Please do not list P. O. Box No.) City Phone Number: State Zip

(

)
DOB Social Security #

Weapon(s) present on Respondent's property

Sex

Race

Weapons involved

and RESPONDENT (person you are filing petition against)

First

Middle

Last

Street (Please do not list P. O. Box No.) City Phone Number: ( State Zip

What is your relationship to the respondent? Do you or any of your clients or witnesses in this case require special accommodations due to disability? Yes No If Yes, Please Specify: Wheelchair accessible hearing room and other facilities Interpreter or other aid for the hearing impaired Reader or other aid for the visually impaired Spokesperson or other aid for the speech impaired Other

)
Proceeding Without an Attorney or I have an attorney (fill in below) Attorney Name: Firm: Address: Telephone: Representing: Dated:

IN CASES INVOLVING DOMESTIC VIOLENCE, Respondent's information must be listed here: (Failure to list certain information may prevent your protective order from being listed on the national "Domestic Violence Registry") RESPONDENT IDENTIFIERS

SEX EYES

RACE HAIR

DOB

HT

WT

SOCIAL SECURITY # YR. OF EXP.

Petitioner

Respondent

DRIVERS LICENSE # STATE
DISTINGUISHING FEATURES

Signature

SCA-DV-FC/M-1200-1 / 11-6-03

Civil Case Information Statement ­ Page 2 of 2

Magistrate Court Case No.:

Family Court Civil Action No.:

For Court Use Only: FILE TRANSFER RECEIPT This case file includes the items below that are checked. Case History Civil Case Information Statement Domestic Violence Petition Order of Protection/Domestic Violence Emergency Protective Order Domestic Violence Petition: Person Who Witnesses or Reports Order of Protection/Domestic Violence Emergency Protective Order: Person Who Witnesses or Reports Domestic Violence Petition for Temporary Emergency Protective Order Order of Protection/Domestic Violence Temporary Emergency Protective Order Respondent Answer Other:

I hereby certify that on the day of from magistrate court and the items indicated were present.

, I received the above case file

of

County, West Virginia

SCA-DV-FC/M-1200-2 / 11-06-03

MAGISTRATE CLERK - COPY