SCA-FC-103: Petitioner's Civil Case Information Statement-Domestic Relations Cases
Review Date: 06/2014; Revision Date: 06/2014; WVSCA Approved: 06/17/2014
Page 1 of 2
IN THE FAMILY COURT OF
COUNTY, WEST VIRGINIA
IN RE:
The Marriage / Children Of:
Case No.
Judge:
Petitioner (First/Middle/Last)
.
and
Respondent (First/Middle/Last)
,
PETITIONER'S CIVIL CASE INFORMATION STATEMENT
DOMESTIC RELATIONS CASES
PETITIONER'S IDENTIFYING INFORMATION IMPORTANT NOTICE
Street Address
City / State / Zip Code
( )
-
Phone Number
Male /
Female
-
-
Social Security Number
/
/
Date of Birth
Race:
American Indian/Alaskan Native
Asian or Pacific Islander
Unknown
Hispanic
Black
White
Check this box if you wish to keep
the information in this box
CONFIDENTIAL because you
fear for your safety and/or the
safety of your children.
If the box above is checked, this
page is sealed in the file and
NOT TRANSMITTED
with the Petition and Summons.
You must complete the form,
Affidavit To Withhold Identifying
Information, and file it at the
Circuit Clerk's Office.
YES
NO
Do you or any of your clients or witnesses in this case require special accommodations due
to a disability?
IF YES, SPECIFY:
Wheelchair accessible hearing room and other facilities;
Interpreter or other auxiliary aid for the hearing impaired;
Reader or other auxiliary aid for the visually impaired;
Spokesperson or other auxiliary aid for the speech impaired;
Other:
Original and
copies of petition enclosed/attached.
