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211 2nd Street NW
Austin MN 55912
USA

507-434-9665

Paternity / Custody / Parenting / Time / Support Form

Paternity / Custody / Parenting / Time / Support

Please attach copies of the following to this questionnaire:

  • One month’s worth of pay-stubs

  • Any previous custody or child support orders

  • Any other documentation you think is important such as police reports, text messaged, etc

 

Consultation Date:
Consultation Date:
Referred By:
Referred By:
Current Personal Information
1. Name: *
1. Name:
3. Present Address: *
3. Present Address:
4. Phone number 1: *
4. Phone number 1:
5. Phone number 2:
5. Phone number 2:
9. Date of Birth: *
9. Date of Birth:
12. Are you presently in the military service?
13. Address for receiving mail, if different than home address:
13. Address for receiving mail, if different than home address:
Your Employment Information
14. Are you currently employed? *
If yes, proceed to question 15. If no, skip to question 23.
16. Employer Address:
16. Employer Address:
19. How often do you get paid?
$
$
per:
List overtime, bonuses, commissions, and other employment.
24. Do you receive, or expect to receive, any of the following as income?
Check all that apply.
Other Parties Personal Information
26. Full Name: *
26. Full Name:
27. Present Street Address: *
27. Present Street Address:
28. Phone number 1: *
28. Phone number 1:
29. Phone number 2:
29. Phone number 2:
32. Date of Birth: *
32. Date of Birth:
37. Are they presently in the military service?
Other Parties Employment Information
38. Is the other party currently employed?
If yes, proceed to question 39. If no, skip to question 47.
40. Employer Address:
40. Employer Address:
43. How often do they get paid?
$
$
per:
List overtime, bonuses, commissions, and other employment.
48. Do they receive, or expect to receive, any of the following as income:
Check all that apply.
Children
Do not list children from previous marriages or relationships.
50. Are there children born from this relationship? *
If yes, proceed to question 51. If no, skip to question 58.
List full name, age, date of birth and social security number.
52. Who do the children live with currently?
53. Legal Custody:
54. Physical Custody:
$
$
58. Is there a history of domestic abuse in your relationship?
59. Has there ever been an Order for Protection in place?
$
$
Health Insurance
Check all that apply.
63. Medical insurance provided by you:
64. Dental insurance provided by you:
65. Optical insurance provided by you:
66. Other insurance provided by you:
67. Medical insurance provided by other party:
68. Dental insurance provided by other party:
69. Optical insurance provided by other party:
70. Other insurance provided by other party:
*We recommend printing this form before submitting.