IN THE 16 CIRCUIT COURT OF JACKSON COUNTY, MISSOURI
FAMILY COURT DIVISION
at Kansas City at Independence
In Re the Matter of:
FAMILY COURT INFORMATION SHEET
Social Sec. No.
Driver's License No.
Home Phone No.
Employer Phone No.
List all unemancipated children who are subjects of this proceeding:
Name (last, first, middle) DOB Social Security No. Children Reside with:
To assist in determining child support, have any of these children ever received welfare or Medicaid?
I certify that:
There are no other related cases
The following are the only cases pending or previously adjudicated in any court related to dissolution of
marriage, custody, visitation, paternity, guardianship, adoption, child support, maintenance, abuse neglect or delinquent behavior
(by the minor child/ren), or adult abuse of or by any parties to this action. I further state that the parties to this action have been
known by other names, as stated below:
Indicate style of related case/case number/court and whether case is pending or closed:
I state that the parties to this action have been known by the following other names:
Each party shall have a continuing duty to update the information on this sheet as necessary until this matter has been disposed.
RULE 68.1 Filing Requirement - Family Court Proceedings
Circuit Court Form 17 - Family Court Information sheet - shall be completed and attached to all initial pleadings filed in the Family Court Division
DO NOT KEEP IN COURT FILE
(Attach additional pages, if necessary)Form 17
CIRCT 1452 08-18-09