Provide Mother's information

Name:Address:
City:    County:
State: Zip:
Phone number:
Email:

Provide Father's Information

Name:Address:
City:    County:
State: Zip:
Phone number:
Email:


Provide Minor Children's Information

List the name and birthdate of each child included in the child support order (Indicate M for male and F for female):



Provide Case Information

Indicate Case Number:

Indicate County where case originated:

Indicate assigned Judge:

Indicate which parent has physical custody of the child(ren):MotherFather

Indicate the date and type of order  (i.e. Divorce Judgment or Order of Filiation:

Indicate whether this is the most recent order:

If no, indicate the date and type of the most recent order:

Indicate the parenting time schedule outlined in the order:

Indicate how the custodial parent has failed to comply with the parenting time order.  (Outline specific incidents, i.e., how parenting time was denied, date, time, and your efforts to secure visitation):



Indicate the total number of parenting time days that have been denied:

Indicate whether you have lost any funds as a result of the denial of parenting time  and have evidence establishing the type and amount of loss (i.e., show tickets, airplane tickets for scheduled trip):


Indicate whether you are seeking reimbursement for any funds lost as a result of denial of parenting time:

 ACKNOWLEDGMENT: Speedy Legal Docs did not provide me with any advice, explanation or representation about any legal rights, remedies, defenses or options.