West Virginia Civil Case Information Statement FormWest Virginia Civil Case Information Statement Form
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CIVIL CASE INFORMATION STATEMENT
DOMESTIC RELATIONS CASES

IN THE FAMILY COURT OF

COUNTY, WEST VIRGINIA

I. CASE STYLE:
IN RE
THE MARRIAGE/CHILDREN OF:
PETITIONER

CASE No.

Judge
Street
City

State

Phone Number : (

Zip

)

Social Security #:

and
Days to
Answer

RESPONDENT

Street
City
Phone Number : (

State

Zip

)

Social Security #:

Original and

SCA-F-103-1 (Revised 12/01)

copies of petition enclosed/attached.

Type of Service

PETITIONER:
RESPONDENT:

CASE NUMBER:

I.

PLEASE CHECK HERE IF EITHER PARTY SEEKS CHILD SUPPORT OR ALIMONY.

II.

PLEASE CHECK IF A FAMILY VIOLENCE PROTECTIVE ORDER IS NOW IN EFFECT.

III.

TYPE OF CASE OR RELIEF: (Check all that apply)
Divorce w/o children
Divorce w/ children

Grandparent Visitation

Annulment
Separate Maintenance

Paternity

Child Support only

Other (specify):

Child Custody w/o Divorce

IV.

DO YOU OR ANY OF YOUR CLIENTS OR WITNESSES IN THIS CASE REQUIRE SPECIAL
YES
NO
ACCOMMODATIONS DUE TO A DISABILITY?

IF YES, PLEASE SPECIFY: