In the Family Court at [place]
No: FAM—
This information sheet accompanies applications for the following order(s): [list orders]
Applicant's full name:
*Home address:
*Work address:
*Email address:
*Contact telephone No: [home, work, mobile]
*Preferred method of contact:
*Emergency contact: [if applying for a protection order, give contact details of another person who can be contacted in an emergency]
Date of birth:
Age:
Gender:
Occupation:
Ethnic origin (select from the following list):
New Zealand European
Māori
Samoan
Cook Island Māori
Tongan
Niuean
Chinese
Indian
Other: [specify]
*Country of residence:
Interpreter required: Yes/No
Language: [specify]
| *The applicant may omit these items from copies to be served. |
Full name of other party (or other applicant (in the case of a joint application)):
Relationship to applicant:
Home address:
Work address:
Contact phone No: [home, work, mobile]
Date of birth:
Age:
Gender:
Occupation:
Ethnic origin (select from the following list):
New Zealand European
Māori
Samoan
Cook Island Māori
Tongan
Niuean
Chinese
Indian
Other: [specify]
Country of residence:
Interpreter required: Yes/No
Language: [specify]
Date of marriage or civil union:
Place of marriage or civil union:
Date by which de facto relationship had begun:
Children affected by the application:
| Full name of each child | | Age | | Date of birth | | M/F | | Ethnic origin* | | Name of person with whom each child is living at time of application and relationship (if any) of that person to child | | Relationship of applicant to child | | Relationship of respondent to child |
| *Select ethnic origin from the following list: |
| 1 | New Zealand European |
| 2 | Māori |
| 3 | Samoan |
| 4 | Cook Island Māori |
| 5 | Tongan |
| 6 | Niuean |
| 7 | Chinese |
| 8 | Indian |
| 9 | Other: [specify] |
| | |
Previous applications: [give file number of any previous applications between the parties, and the court where they were filed]
Existing orders between the parties: [give details of any existing order between the parties, including the date the order was made, the court that made the order, and the court file number]
Existing orders relating to any child: [give details of any existing order relating to any child affected by the application, including the date the order was made, the court that made the order, and the court file number]
Previous attendance at a safety programme: [if you have previously attended a safety programme provided by a service provider and wish to attend a further programme with that provider, give the name of that service provider]
Date stamp:
The accompanying applications are filed by:
Address for service: