Free FC-3 - Kentucky

AOC-FC-3 01/9/2007 11:46 am Rev. 7-05 Ver. 1.01 Commonwealth of Kentucky Court of Justice www.kycourts.net [ ] Minor Children Involved [ ] Protective Order Issued For: Use mouse to [ ] Petitioner select [ ] Respondent
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[ ] CIRCUIT [ ] DISTRICT [ ] FAMILY COURT CASE DATA INFORMATION SHEET

Case #: ______________________ County / Division: _______________

PETITIONER: Name: _______________________________________ Address: _____________________________________ _____________________________________________ _____________________________________________ Telephone: ( ______ ) ___________________________ DOB: ________________________________________ SSN: ________________________________________ Relationship to Respondent: ______________________

RESPONDENT: Name: _______________________________________ Address: _____________________________________ _____________________________________________ _____________________________________________ Telephone: ( ______ ) ___________________________ DOB: ________________________________________ SSN: ________________________________________ Relationship to Petitioner: ________________________

For ALL OTHER PARTIES to this case: please list below the name, current address, date of birth (DOB), social security number (SSN), and relationship to the Petitioner, of any other parties to this action, or children of the Petitioner or Respondent. If there is not enough room below, please attach a separate sheet with all the information requested. OTHER PARTIES / CHILDREN: Name: _______________________________________ Address: _____________________________________ _____________________________________________ _____________________________________________ Telephone: ( ______ ) ___________________________ DOB: ________________________________________ SSN: ________________________________________ Relationship to Petitioner: ________________________ Name: _______________________________________ Address: _____________________________________ _____________________________________________ _____________________________________________ Telephone: ( ______ ) ___________________________ DOB: ________________________________________ SSN: ________________________________________ Name: _______________________________________ Address: _____________________________________ _____________________________________________ _____________________________________________ Telephone: ( ______ ) ___________________________ DOB: ________________________________________ SSN: ________________________________________ Relationship to Petitioner: ________________________ Name: _______________________________________ Address: _____________________________________ _____________________________________________ _____________________________________________ Telephone: ( ______ ) ___________________________ DOB: ________________________________________ SSN: ________________________________________

Relationship to Petitioner: ________________________ Relationship to Petitioner: ________________________ Please list any / all cases, pending, or heard within the last five (5) years, that have involved the parties or children of the parties in Family, District or Circuit Court. Please provide the case number, name of party and type of case: _________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _____________________________________________ Signature of Preparer / Relationship to Petitioner This form shall be completed in full, pursuant to local rule and in compliance with federal law. Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ Phone: ( ______ ) ______________________________

DISTRIBUTION: Cabinet for Families and Children, placing a copy in the County Attorney's Wage Withholding Order Box in Circuit Clerk's Office

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