Title

Mr.Mrs.Ms.MissDr.Hon.Rep.Sen.

First Name*

Last Name*

Suffix

Email address*:

City

State*
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Zip Code*

Phone Number

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?