Wayne County Court of Common Pleas

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Wayne County Court of Common Pleas Domestic Relations Division NEW CASE DESIGNATION FORM Instructions: Pursuant to Local Rules, this form must be completed and submitted with any new cause of action filed with the Wayne County Clerk of Courts. The Social Security Numbers will NOT be public record. Case Type: (e.g. dissolution, dissolution with children, divorce, divorce with children, parentage, visitation rights, etc.) Plaintiff Information: Defendant Information: First Name: Middle Initial: First Name: Middle Initial: Last Name: Suffix: Last Name: Suffix: Address: Address: City: State: Zip: City: State: Zip: SSN: DOB: SSN: DOB: Telephone: Email: Telephone: Email: Plaintiff Attorney Information: □ Pro Se Defendant Attorney Information: (if known) Attorney Name: Attorney Name: Ohio Sup Ct #: Telephone: Ohio Sup Ct #: Telephone: Firm Name: Firm Name: Address: Address: City: State: Zip: City: State: Zip: Child Information: 1 st Child Name: DOB: SSN: Address: City: State: Zip: 2 nd Child Name: DOB: SSN: Address: City: State: Zip: 3 rd Child Name: DOB: SSN: Address: City: State: Zip: ** If additional space is needed to list children related to these proceedings, attach additional forms. __________________________________________ Attorney for Plaintiff (or pro se litigant) For Official Use Only: Case No.: ______________ SETS No.: ______________