(4) Child’s Name
Place of Birth
Birthdate
Sex
Marital Status
School Grade
Present Address (since
/
/
)
Who Has Custody
Relationship
Prior Residences for
City & State
Person child lived with
Relationship
past 5 years (dates)
(Name & Current Address)
to
to
to
B. Has either Party A or Party B participated as a party, a witness, or in another capacity in
another proceeding concerning the custody of any of the above children or visitation with
them?
Yes
No
If yes, describe the previous child custody determination:
Name of Court
Case Number
Date
Court’s Decision
C. Does either Party A or Party B know of a proceeding that could affect this dissolution case
(such as a proceeding relating to domestic violence, protective orders, termination of
parental rights, adoption or enforcement of a court order)?
Yes
No
If yes, describe: Name of Court
Case Number
Nature of Proceeding
D. Does either Party A or Party B know of any person not a party to this dissolution case who
has physical custody of any of the above children or claims to have the right to physical
custody, legal custody, or visitation?
Yes
No
If yes, list each person’s name and address, and what the person claims:
E. Is Party A or Party B pregnant?
Yes
No
If yes, include arrangements for this child in the following sections.
F. Is paternity disputed regarding any child?
Yes
No
Has paternity been disestablished for any child born during the marriage?
Yes
No
If you answer yes to either of these questions, there may be additional requirements.
NOTE: You both have a continuing duty to inform the court of any other court
proceeding in this state or any other state concerning any of the children listed
above.
Signature of Party A
Signature of Party B
Page 9 of 17
DR-105 (8/15)(cs)
AS 25.24.200-.260
PETITION FOR DISSOLUTION OF MARRIAGE (WITH CHILDREN)
Civil Rule 90.1(a), f(2)(A)(B), (i)(1)