Name:
Maiden Name:
Current Address:
Email Id:
Telephone:
(H) (C) (W)
Duration of residence in NY state:
If under one year, prior address:
Social security number:
Date of Birth:
Place of Birth:
Highest level of education:
Employer
Address:
How long:
Position/Title:
Earnings:
if unemployed, how long:
Reason:
Current health insurance
Name:
Address:
Parties Covered:
Type of Coverage:
Account Number:
Date of marriage:
Place of marriage:
Civil or Religious Ceremony:
Number of years lived together:
Address of last marital residence:
Date of separation (by either party):
Marital Assets
1:
2:
3:
4:
5:
6:
Separate assets (acquired prior to marriage)
1:
2:
3:
Spouse Name:
Spouse Current Address:
If unknown, last known address:
Spouse social security number:
Spouse date of birth:
Employer
Address:
How long:
Position/Title:
Earnings:
Current Health Iinsurance
Name:
Address:
Parties Covered:
Type of Coverage:
Account Number:
Either party union member
Name:
Children of the marriage
1: Name:
Date of Birth:
2: Name:
Date of Birth:
3: Name:
Date of Birth:
Either party in military:
Either party incarcerated:
GROUNDS (Choose one or more that applies)
1. Abandonment
Date of Abandonment:
Address of Abandonment:
Decription of how occurred:
2. Constructive Abandonment (for parties still living together)
Date of Abandonment:
Address of Abandonment:
Type of Abandonment:
Refusal to have sex:
Spouse excluded party from the home:
Any physical impairments preventing sex:
3. Imprisonment
Where incarcerated:
How long:
Inmate number:
4. Separation agreement (include copy)
where filed:
when filed:
5. Cruel and inhuman treatment
A: verbal abuse
Describe (give dates, locations, what said, witnesses, etc.):
B: Physical abuse
Describe (give dates, locations, injuries, witnesses, etc.) :
Any police reports, hospital records, Family Court petitions/orders:
If Yes, please discribe:
C: Economic abuse
Describe (give dates, locations, how, etc.):
D: Alcohol or drug abuse
Describe (give frequency, behavior, etc.):
E: Other abuse
Describe:
6. Adultery
Describe (include proof in possession):
Other Relief Requested (including interim relief)
Alimony:
Custody or Visitation:
Child Support:
Equitable Distribution (real property, personal property, pension, etc.):
Attorney's Fees:
Appraiser Fees:
Other:
***Keep in mind request for certain relief will be contested matter***
NOTES/COMMENTS:
Verification Code:
