CIVIL CASE INFORMATION STATEMENT DOMESTIC VIOLENCE CASES
IN THE MAGISTRATE/FAMILY COURT OF COUNTY, WEST VIRGINIA
CASE STYLE: IN RE
THE DOMESTIC VIOLENCE CIVIL PROCEEDING OF:
Magistrate Court Case No.: Family Court Civil Action No.: Family Court Judge
PETITIONER (person filling out this form)
" Please keep my address and the addresses of other
First Middle Last protected persons confidential because I fear for my/their safety.
Street Address (Please do not list P.O. Box No.) City Phone Number: ( Sex Race ) DOB Social Security # State Zip
" I do not want my order in the National Domestic
Violence Registry. (Checking this box may hinder enforcement of a protective order)
" Weapon(s) present on Respondent's property " Weapons involved
RESPONDENT (person you are filing petition against)
First Middle Last
Street Address (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
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 RACE DOB EYES HAIR HT WT
" Proceeding Without an Attorney
" I have an attorney (fill in below)
Attorney Name: Firm: Address: Telephone: Representing:
SOCIAL SECURITY # STATE YR. OF EXP.
DRIVERS LICENSE #
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 ________________________, I received the above case file from magistrate court and the items indicated were present.
________________________________________ of _________________________County, West Virginia CIRCUIT CLERK
SCA-DV-FC/M-1200-2 / 11-06-03
MAGISTRATE CLERK - COPY