Free Family Law Case Demographics Information Sheet (FL/E-ME-811) - California

FL/E-ME-811

Family Law Case Demographics Information Sheet for Child Custody/Visitation
Court Case Number: ____________________ Family Court Services Number: _____________________

Petitioner's Information
First Name Middle Initial Last Name First Name

Petitioner's Attorney Information

Middle Initial

Last Name

Street Number/Apt. or Suite #

Street Number/Apt. or Suite #

City

State

Zip Code

City

State

Zip Code

Date of Birth: Month Home Phone: Work Phone: Other Phone: ( ( ( ) ) ) Day Year Work Phone: Other Phone: ( ( ) )

Respondent's Information
First Name Middle Initial Last Name First Name

Respondent's Attorney Information

Middle Initial

Last Name

Street Number/Apt. or Suite #

Street Number/Apt. or Suite #

City Date of Birth: Month Home Phone: Work Phone: Other Phone: ( ( ( ) ) )

State

Zip Code

City

State

Zip Code

Day

Year Work Phone: Other Phone: ( ( ) )

FL/E-ME-811 (Revised 4/13/2009) Mandatory

Family Law Case Demographics Information Sheet

Page 1 of 3 Local Rule 14.08(C) (2) www.saccourt.ca.gov

FL/E-ME-811

Court Case Number: ____________________

Family Court Services Number: _____________________ Claimant's Attorney Information (Third Party)

Claimant's Information
First Name Middle Initial Last Name

First Name

Middle Initial

Last Name

Street Number/Apt. or Suite #

Street Number/Apt. or Suite #

City Date of Birth: Home Phone: Work Phone: Other Phone: Month ( ( ( ) ) )

State Day

Zip Code Year

City

State

Zip Code

Work Phone: Other Phone:

( (

) )

Claimant's Information
First Name Middle Initial Last Name

Claimant's Attorney Information (Third Party)

First Name

Middle Initial

Last Name

Street Number/Apt. or Suite #

Street Number/Apt. or Suite #

City Date of Birth: Home Phone: Work Phone: Other Phone: Month ( ( ( ) ) )

State Day

Zip Code Year

City

State

Zip Code

Work Phone: Other Phone:

( (

) )

Minor's Counsel Attorney Information First Name Middle Initial Last Name

Street Number/Apt. or Suite #

City

State

Zip Code

Work Phone: Other Phone:

( (

) )
Family Law Case Demographics Information Sheet Page 2 of 3 Local Rule 14.08(C) (2) www.saccourt.ca.gov

FL/E-ME-811 (Revised 4/13/2009) Mandatory

FL/E-ME-811

Court Case Number: ____________________

Family Court Services Number: _____________________

1.

List all children of the parties: Name Date of Birth Age School Resides with

2.

Please check all boxes that apply. a. Are you currently restrained by a Restraining Order or ever been restrained by a Restraining Order (domestic violence restraining order, emergency protective order, or criminal protective order)? b. Do you have a restraining order against the other party now(domestic violence restraining order, emergency protective order, or criminal protective order)? a. Number of previous mediation appointments:

Yes Yes

No No

3. None One Two Three

Four or more
No No No No

b. Do Petitioner/Respondent live 2-4 hours apart from each other? c. Do Petitioner/Respondent live more than 4 hours apart from each other? d. Is one or more of your children a Special Needs Child? e. Has there been past non-compliance with a Court Order? 4. a. b. c. d. e. f. g. 5. a. Are you or the other parent planning on moving out of the area? b. Does either parent pose a flight risk? Please note whether each or any of these issues are involved in your case: Custody Change Domestic Violence Substance Abuse Mental Health Current or Previous CPS Involvement Child Physical/Sexual Abuse Child Neglect

Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes



No No No No No No No



Yes Yes

No No

FL/E-ME-811 (Revised 4/13/2009) Mandatory

Family Law Case Demographics Information Sheet

Page 3 of 3 Local Rule 14.08(C) (2) www.saccourt.ca.gov