Petition For Dissolution Of Marriage Page 2
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15C. Date and place of marriage:
D. Does either spouse require medical care or treatment?
Yes
No
If yes, state which spouse and describe the care or treatment required:
Is either spouse covered by health insurance (through an employer or otherwise)?
Yes
No
If yes, state which spouse and the amount paid for the insurance by the spouse or spouses:
E. Have any of the following been issued or filed during the marriage by or regarding either
spouse as defendant, participant, or respondent:
1. a criminal charge of a crime involving domestic violence;
2. a domestic violence protective order under AS 18.66.100-18.66.180;
3. injunctive relief against domestic violence under former AS 25.35.010 or 25.35.020; or
4. a domestic violence protective order issued in another jurisdiction and filed with the court
in this state under AS 18.66.140?
Yes
No
If yes, describe:
Has there been any domestic violence during the marriage (whether or not a complaint was
filed)?
Yes
No
F. Has either spouse received advice from legal counsel about a divorce or dissolution?
Yes
No
If yes, state which spouse(s):
Is either spouse represented by legal counsel?
Yes
No
If yes, state which spouse(s):
Husband’s Signature
Wife’s Signature
Page 2 of 15
DR-105 (4/09)(cs)
AS 25.24.200-.260
PETITION FOR DISSOLUTION OF MARRIAGE (WITH CHILDREN)
Civil Rule 90.1(a), f(2)(A)(B), (i)(1)
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