Title Mr.Mrs.Ms.MissDr.Hon.Rep.Sen. First Name* Last Name* Suffix Email address*: City State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming Zip Code* Phone Number Referred By (Individual) 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?(Please enter a number only) 4) In days, what is the longest time you have endured between periods of physical contact with your child? Leave this field empty if you're human:
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