Matrimonial Action Information Page 3
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1
2
3Primary
Secondary
Welfare
Primary
Secondary
Welfare
GROSS MONTHLY INCOME
(All Sources)
DATE
COUNTY/STATE
DATE OF THIS MARRIAGE
DATE
COUNTY/STATE
DATE OF SEPARATION
NOT SEPARATED
CASE NUMBER
MATRIMONIAL ACTION INFORMATION (Continued)
FC-D NO.
TERMINATED BY
FROM
T O
STATE
MONTH/YEAR
MONTH/YEAR
DIVORCE
ANNULMENT
DEATH
WIFE’S PRIOR
MARRIAGES
HUSBAND’S PRIOR
MARRIAGES
CHILDREN:
ALL CHILDREN OF EITHER PARTY FROM YOUNGEST TO OLDEST
PRESENT
LEGAL PARENT
CHILD’S FULL NAME
M/F
BIRTHDATE
CUSTODY
SCHOOL AND GRADE
(HUSBAND, WIFE OR OTHER
INFORMATION REQUIRED FOR CUSTODY
:
CHILDREN’S PRESENT ADDRESS
PLACES WHERE AND PERSONS WITH WHOM THE CHILDREN HAVE LIVED WITHIN THE LAST FIVE YEARS AND DATES
FROM
T O
ADDRESS
CARETAKERS
MONTH/YEAR
MONTH/YEAR
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