Date:
Re: Marriage of:
1. About the marriage:-
Date:
Place:
2. Date of separation:
3. Residence:
-
I have resided in this state for __ years and in the County of __________ for __ years.
My spouse resided in this state for ___ years and in the County of ____________ for __ years.
4. The divorce is desired by: ___ Husband ___ Wife
5. There are ___ children born or adopted into this marriage (further information below).
6. Description of any acts of harassment or violence:
ABOUT MYSELF
7. Name:
8. Telephones:
-
Home: (_____) ___________________
Work: (_____) ___________________ OK to phone at work? ___ Yes ___ No
Other: (_____) ___________________ OK to leave message? ___ Yes ___ No
9. Sex: ____ Age: ____ Date of birth: ____________________
10. Addresses:
-
Mailing address:
Residence address:
County of residence: ______________ How long?
11. Former name(s):
12. I do not wish a former name restored.
I want my former name restored as follows:
13. Employer:
-
Address:
Days and times at work:
Length of this employment: _____
Approximate monthly gross pay: $ ___________
There is medical / dental coverage through my employer:
-
____ for me ____for my spouse ____for children ____No coverage
Monthly cost: $___________
My Social Security number:
My driver's license number:
Cost of child care enabling me to work is $_____________ per month.
14. Other sources of income (give approx. amount per month):-
a)
b)
c)
15. Health problems for which special attention or care is necessary:
16. Other than my spouse or children, I am currently residing with (name, age, relationship to you):
Monetary arrangements with people listed above:
17. Will-
___ I have no will.
___ My most recent will was made on:
ABOUT MY SPOUSE
18. Name:
19. Telephones:
-
Home: (_____) ___________________
Work: (_____) ___________________ OK to phone at work? ___ Yes ___ No
Other: (_____) ___________________ OK to leave message? ___ Yes ___ No
20. Sex: ____ Age: ____ Date of birth: ____________________
21. Addresses:
-
Mailing address:
Residence address:
County of residence: ______________ How long?
22. Former name(s):
23. Spouse does not wish a former name restored.
Spouse does want a former name restored as follows:
24. Employer:
-
Address:
Days and times at work:
Length of this employment: _____
Approximate monthly gross pay: $ ___________
There is medical / dental coverage through my spouse's employer:
-
____ for me ____for my spouse ____for children ____No coverage
Monthly cost: $________
Spouse's Social Security number:
Spouse's driver's license number:
Cost of child care enabling spouse to work is $______ per month.
25. Other sources of income (give approx. amount per month):-
a)
b)
c)
26. Health problems for which special attention or care is necessary:
27. Other than our children, my spouse is currently residing with (name, age, relationship to you):
Monetary arrangements with people listed above:
28. Spouse's attorney is:-
Address:
CHILDREN BORN OR ADOPTED INTO THIS MARRIAGE
29. For each child, list name, age, birthdate, Social Security number, and who the child resides with:
-
There (is) (is not) likely to be any dispute about the paternity of any of the children.
30. Special health care problems:
31. Income or property owned by any dependent children:
32. Custody and visitation of children:-
a) is currently arranged and is working out as follows:
b) I want the judgment to order custody and visitation rights as follows:
c) I anticipate that there (will) (will not) be a dispute over custody and visitation.
MY PREVIOUS MARRIAGES & RELATIONSHIPS
33. I was previously married __ times before this marriage.
List name of each former spouse, when the marriage was terminated, and how (death, divorce, etc.)
-
a)
b)
c)
34. Children born or adopted into previous marriages (for each, list name, age, birthdate, Social Security number, and who the child resides with):
35. Children from a non-marital relationship (for each, list name, age, birthdate, Social Security number, and who the child resides with):
36. Support paid or received (including any overdue) by me or by the above children, or other income (such as Social Security) received by or on behalf of the above children, is as follows:
MY SPOUSE'S PREVIOUS MARRIAGES & RELATIONSHIPS
37. My spouse was previously married ____ times before this marriage.
List name of each former spouse, when the marriage was terminated, and how (death, divorce, etc.)
-
a)
b)
c)
38. My spouse's children born or adopted into previous marriages (for each, list name, age, birthdate, Social Security number, and who the child resides with):
39. My spouse's children from a non-marital relationship (for each, list name, age, birthdate, Social Security number, and who the child resides with):
40. Support paid or received (including any overdue) by my spouse or by the above children, or other income (such as Social Security) received by or on behalf of the above children, is as follows:
CURRENT ARRANGEMENTS
41. Separation:
-
____ We are not yet separated
____ We are separated but have no financial arrangements at this time.
____ We have separated and now live apart under the following financial arrangements:
Periodic payments (who pays, how much, for what, how often):
Direct payments (Mortgage, bills, et cetera.) (List each item, who pays, how much and how often paid):
Other arrangements:
42. Arrangements, agreements:-
____ We have made no written agreements and have no oral understandings.
____ We have a written agreement which is attached.
____ We have oral agreements or understandings as follows:
PENDING ISSUES AND QUESTIONS
43. I foresee the following problems in dealing with my spouse (i.e., fear, distrust, dishonesty, unwillingness to compromise, using children as a weapon, violence, et cetera):
44. I have some questions and issues I would like to explore, as follows:
45. I have already made some decisions about what outcome I would like with respect to property, children, support, or goals and conduct of this case, as follows: