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Juan Fernandez-Barquin

Clerk of the Court and Comptroller

Miami-Dade County

Domestic Violence Intake Questionnaire


Note: a printer is required after filling out this questionaire as you will need to take it with you to the Intake office.
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The following information is requested about YOU (the Petitioner):
Name*
Email*
Birth Date*
 
Place of Birth
Gender
Address
City
State
Zip Code
Phone Number*
Alternate Phone Number
Ethnic Origin
Race
Name and Relation of Contact Person
Contact Person Telephone Number
Employment Information:
Employer
Employer's Address
Employer's City
Employer's State
Employer's Zip Code
Employer's Phone Number
Extension
Items marked with an asterisk (*) are required.

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