Client Full Name: First Middle Last

Client's Preferred Phone #:

Client's Secondary Phone #:

Client's Phone for Text Messages:

Your Social Security Number

County Where Case is/to be filed

Case Number (if any)

Parent's Information (Parent 1)

Title of Parent (Parent 1):

Mr

Ms

Miss

Mrs

Dr

Other

Please state:

Parent's Preferred Name (Parent 1):

(please leave blank if not necessary)

Parent's Email Address (Parent 1):

Parent's Preferred Daytime Contact Number (Parent 1):

Parent's Preferred Evening Contact Number (Parent 1):

Parent's Cell Number (Parent 1):

Parent's Residential Address (Parent 1):

Parent's Residential City (Parent 1):

Parent's Residential State (Parent 1):

Parent's Residential Zip Code (Parent 1):

Parent's Residential County (Parent 1):

Parent's Service Address (Parent 1):

You may list an address that is not your residential address where you agree to accept legal documents

Parent's Service City (Parent 1):

Parent's Service State (Parent 1):

Parent's Service Zip (Parent 1):

Parent's Employer (Parent 1):

Parent's Employer Phone (Parent 1):

Parent's Employer Address (Parent 1):

Parent's Employer City (Parent 1):

Parent's Employer State (Parent 1):

Parent's Employer Zip (Parent 1):

Parent's Social Security Number (Parent 1):

Parent's Driver's License/ID & State (Parent 1):

Parent's Date of Birth (Parent 1):

Parent's Birth State (Parent 1):

Parent's Birth Last/Maiden Name (Parent 1)

County Where Married (Parent 1):

State Where Married (Parent 1):

Parent's Ethnicity (Parent 1):

Parent's Relationship To Child(ren) (Parent 1):

Parent's Gender (Parent 1):

Select an option Male Female Trans Male To Female Trans Female to Male Non-Binary

Parent's Information (Parent 2)

Title of Parent (Parent 2):

Mr

Ms

Miss

Mrs

Dr

Other

Please state:

Parent's First Name (Parent 2):

Parent's Middle Name (Parent 2):

Parent's Last Name (Parent 2):

Parent's Preferred Name (Parent 2):

(please leave blank if not necessary)

Parent's Email Address (Parent 2):

Parent's Preferred Daytime Contact Number (Parent 2):

Parent's Preferred Evening Contact Number (Parent 2):

Parent's Cell Number (Parent 2):

Parent's Residential Address (Parent 2)

Parent's Residential City (Parent 2)

Parent's Residential State (Parent 2)

Parent's Residential Zip Code (Parent 2)

Parent's Residential County (Parent 2)

Parent's Service Address (Parent 2):

You may list an address that is not your residential address where you agree to accept legal documents

Parent's Service City (Parent 2):

Parent's Service State (Parent 2):

Parent's Service Zip (Parent 2):

Parent's Employer Name (Parent 2):

Parent's Employer Phone (Parent 2):

Parent's Employer Address (Parent 2):

Parent's Employer City (Parent 2):

Parent's Employer State (Parent 2):

Parent's Employer Zip (Parent 2):

Parent's Social Security Number (Parent 2):

Parent's Driver's License/ID & State (Parent 2):

Parent's Date of Birth (Parent 2):

Parent's Birth State (Parent 2)

Parent's Birth Last/Maiden Name (Parent 2):

County Where Married (Parent 2):

State Where Married (Parent 2):

Parent's Ethnicity (Parent 2):

Parent's Relationship To Children (Parent 2)

Parent's Gender (Parent 2):

Select an option Male Female Trans Male To Female Trans Female to Male Non-Binary

Marriage & Children

Dissolution of Marriage - Petitioner

Dissolution of Marriage - Respondent

Date of Marriage

City of Marriage

State of Marriage

Obligor for Child Support

Select an option Parent 1 Parent 2

Obligee for Child Support

Select an option Parent 1 Parent 2 None

Eldest Child's First Name

Eldest Child's Last Name:

Eldest Child's Age

Eldest Child's Date of Birth?

Eldest Child's Social Security Number

Who Does Eldest Child Reside With?

Select an option Parent 1 Parent 2 None of the Above/Not-Applicable

Is The Parent The Eldest Child Resides With The Child's Legal Guardian?

Should The Eldest Child Be Included In Relocation Action?

Select an option Yes No

Second Child's First Name

Second Child's Last Name:

Second Child's Age

Second Child's Date of Birth?

Second Child's Social Security Number

Who Does Second Child Reside With?

Select an option Parent 1 Parent 2 None of the Above/Not-Applicable

Is The Parent The Second Child Resides With The Child's Legal Guardian?

Should The Second Child Be Included In Relocation Action?

Select an option Yes No

Third Child's First Name (if applicable)

Third Child's Last Name (If applicable):

Third Child's Age (If applicable):

Third Child's Date of Birth (If applicable):

Third Child's Social Security Number (If applicable):

Who Does The Third Child Reside With (If applicable):

Select an option Parent 1 Parent 2 None of the Above/Not-Applicable

Is The Parent The Third Child resides With The Child's Legal Guardian (If applicable):

Should The Third Child Be Included In Relocation Action (If applicable):

Select an option Yes No

Fourth Child's First Name (if applicable)

Fourth Child's Last Name (If applicable):

Fourth Child's Age (If applicable):

Fourth Child's Date of Birth (If applicable):

Fourth Child's Social Security Number (If applicable):

Who Does The Fourth Child Reside With (If applicable):

Select an option Parent 1 Parent 2 None of the Above/Not-Applicable

Is The Parent The Fourth Child resides With The Child's Legal Guardian (If applicable):

Should The Fourth Child Be Included In Relocation Action (If applicable):

Select an option Yes No

Fifth Child's First Name (if applicable)

Fifth Child's Last Name (If applicable):

Fifth Child's Age (If applicable):

Fifth Child's Date of Birth (If applicable):

Fifth Child's Social Security Number (If applicable):

Who Does The Fifth Child Reside With (If applicable):

Select an option Parent 1 Parent 2 None of the Above/Not-Applicable

Is The Parent The Fifth Child resides With The Child's Legal Guardian (If applicable):

Should The Fifth Child Be Included In Relocation Action (If applicable):

Select an option Yes No

If This Is A NONPARENTAL CUSTODY Proceeding Please Type Children's Name(s) For Which Custody Is Being Sought:

ATTORNEY INFORMATION

Please Select Who The Opposing Counsel Represents:

Select an option Petitioner Respondent

Opposing Counsel Name:

Opposing Counsel W.S.B.A#:

Opposing Counsel Firm Name:

Opposing Counsel Phone Number:

Opposing Counsel Pager (if applicable)

Opposing Counsel Address:

Opposing Counsel City:

Opposing Counsel State:

Opposing Counsel Zip:

COMPLETING ATTORNEY INFORMATION

Completing Counsel Name:

Completing Counsel W.S.B.A#:

Completing Counsel Firm Name:

Completing Counsel Phone Number:

Completing Counsel Pager (if applicable)

Completing Counsel Address:

Completing Counsel City:

Completing Counsel State:

Completing Counsel Zip:

FINANCIAL DECLARATION

Your Full Name

The Highest Year of Education Completed:

For example 'High School' or 'Bachelors'

Are you currently working?

Yes

Job Title/Profession Date You Were Hired Date you last worked What was your monthly pay before Taxes?

No

Why Are You Not Currently Working?

FINANCIAL INCOME - YOU (PERSON 1)

Gross Monthly Income (before taxes, deductions or retirement contributions)

Imputed Monthly Income

Monthly Wage/Salary: Income from Interest/Dividends Per Month: Income From Business Per Month: Spousal Support/ Maintenance received Per Month: If in receipt of Spousal Support/Maintenance - who is this paid by? Child Support Received from other Relationships: Any other income: Total Gross Monthly Income (add all lines above):

Monthly Deductions

Please Ensure All Monthly Deductions Are Listed Below;

Income Taxes (Federal & State): FICA (Soc.Sec. + Medicare) or Self-Employment Taxes: State Industrial Insurance (Workers Comp.): Mandatory Union or Professional Dues: Mandatory Pension Plan Payments: Voluntary Retirement Contributions (up to the limit in RCW 26.19.0719(5)(g)): Spousal Support/Maintenance Paid: Normal Business Expenses: Total Monthly Deductions:

FINANCIAL INCOME - (PERSON 2)

Gross Monthly Income (before taxes, deductions or retirement contributions)

Imputed Monthly Income

Monthly Wage/Salary: Income from Interest/Dividends Per Month: Income From Business Per Month: Spousal Support/ Maintenance received Per Month: If in receipt of Spousal Support/Maintenance - who is this paid by? Child Support Received from other Relationships: Any other income: Total Gross Monthly Income (add all lines above):

Monthly Deductions

Please Ensure All Monthly Deductions Are Listed Below;

Income Taxes (Federal & State): FICA (Soc.Sec. + Medicare) or Self-Employment Taxes: State Industrial Insurance (Workers Comp.): Mandatory Union or Professional Dues: Mandatory Pension Plan Payments: Voluntary Retirement Contributions (up to the limit in RCW 26.19.0719(5)(g)): Spousal Support/Maintenance Paid: Normal Business Expenses: Total Monthly Deductions:

Are there any additional adults living in the home

Yes

please list the gross monthly total of additional adults

No

Disputed Income - if you disagree with the other party's statements about anyone's income, explain why the other party's statements are not correct, and your statements are correct:

AVAILABLE ASSETS

Cash on hand and money in all checking & savings accounts:

Stocks, Bonds, CD's and other liquid financial accounts:

Cash value of life insurance:

Other Liquid Assets:

Total Available Assets:

MONTHLY EXPENSES AFTER SEPARATION

(Housing Expenses) = Rent:

(Housing Expenses) = Property Tax:

(Housing Expenses) = Homeowner's or Rental Insurance:

(Housing Expenses) = Other mortgage, contract or debt payments based on equity in your home:

(Housing Expenses) = Homeowner's Association dues or fees

(Transportation Expenses) = Automobile Payment (loan or lease)

(Transportation Expenses) = Auto Insurance, License, Registration

(Transportation Expenses) = Gas & Auto Maintenance

(Transportation Expenses) = Parking, Tolls & Public Transportation

(Transportation Expenses) = Other Transportation Expenses

(Utilities Expenses) = Electricity & Heating (Gas & Oil)

(Utilities Expenses) = Water, Sewer & Garbage

(Utilities Expenses) = Telephone(s)

(Utilities Expenses) = Cable/Internet

(Utilities Expenses) = Other Utilities - please specify

Personal Expenses (Not Children) = Clothing

Personal Expenses (Not Children) = Hair & Personal Care

Personal Expenses (Not Children) = Recreation, Clubs, Gifts

Personal Expenses (Not Children) = Education, Books, Magazines

Personal Expenses (Not Children) = Other Personal Expenses

(Food & Household Expenses) = Groceries

(Food & Household Expenses) = Household Supplies Such As Cleaning Products, Paper, Pets etc

(Food & Household Expenses) = Eating Out

(Food & Household Expenses) = Other, Please Specify

(Children's Expenses) = Childcare, Baby-Sitting

(Children's Expenses) = Clothes, Diapers

(Children's Expenses) = Tuition, After School Programs & Lessons

(Children's Expenses) = Other Expenses - Please Specify

(HealthCare Expenses) = Insurance Premium (Health, Vision. Dental)

(HealthCare Expenses) = Health, Vision, Dental, Orthodontia, Mental Health or Other Health Expense Not Covered By Insurance

(HealthCare Expenses) = Life Insurance That Is Not Deducted From Pay

Debts Included In Monthly Expenses (Such as Credit Cards)

Explanation of Expenses or debts (If applicable)

Financial Records - You must provide financial records as required by the statute and state and local court rules. These records may include Personal Income Tax Returns, Pay Stubs, Partnership or Corporate Income Tax Returns or Other Financial Records.

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RESTRAINED PERSON - PERSONAL INFORMATION

Ethnicity

Relationship to Protected Person

Height

Weight

Skin Tone

Build

If different to the above - where can the restrained person be served?

Social Media Accounts & User Names

Vehicle information (such as Make, Model, License Number, Vehicle Color, Vehicle Year)

RESTRAINED INFORMATION - DISABILITY, HAZARD & WEAPON INFORMATION

Does the Restrained Person have a disability, brain injury or impairment requiring special assistance when law enforcement serves the order?

Yes

Please provide details:

No

Hazard Information - Restrained Person's History Includes;

Involuntary/Voluntary CommitmentSuicide Attempts and/or ThreatsThreats To "suicide by cop"AssaultAssault with WeaponsAlcohol/Drug AbuseOther

Concealed Pistol's License:

HandgunsRiflesKnivesExplosivesUnknownOther (include unassembled firearms and specify)

Location of Weapons

VehicleOn PersonResidence

Is the restrained person a current or former cohabitant as an intimate partner?

Yes

No

Are you and the restrained person living together now?

Yes

No

Does the restrained person know they may be moved out of the home?

Yes

No

Does the restrained person know you are trying to get this order?

Yes

No

Is the restrained person likely to react violently when served?

Yes

No

ATTORNEY FEES

Amount Paid (To Date)

Amount Still Owed

Source Of The Money You Used To Pay These Fees & Costs (for example 'loan')

Describe your agreement with your attorney to pay your fees and costs

CONFIDENTIAL INFORMATION

Is there a current restraining order or protection involving the parties or children? If Yes please provide information below including who the Order protects.

Does your address (or other information) need to be kept confidential to protect you or your child(ren)'s health, safety or liberty?

Have the children lived with anyone other than you or the other party during the last 5 years?

Do other people (not parents) have custody or visitation rights to the children?

Financial Records - You must provide financial records as required by the statute and state and local court rules. These records may include Personal Income Tax Returns, Pay Stubs, Partnership or Corporate Income Tax Returns or Other Financial Records.

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ACKNOWLEDGEMENT & ACCEPTANCE

THANK YOU