Title
Mr. Mrs. Ms. Miss Dr. Hon. Rep. Sen.

First Name*

Last Name*

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Email address*:

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If applicable please answer the following:

1) What county has jurisdiction over your case?

2) What judge is current or has previously presided over your case?

3) How many overnights a month have you been awarded?

4) In days, what is the longest time you have endured between periods of physical contact with your child?