Background Information For Apl Petition Form
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1BACKGROUND FOR APL PETITION
Name of Petitioner
Social Security Number_____________________
Address________________________________________________________________________________
Date of Birth
Place of Birth
Phone #_______________
Maiden name of Petitioner
Name of Attorney______________________
Name and Address of employer___________________________________________________________
Occupation
Average weekly net income________________________
Name of Respondent_
Social Security Number_____________________
Address________________________________________________________________________________
Date of Birth
Place of Birth
Phone #
___
Name and Address of employer___________________________________________________________
Occupation
Average weekly net income________________________
Respondent’s military service
Respondent’s Atty.__________________
Race
Height
Weight
Color hair
Eyes____________
Respondent’s Father’s name and address
_________________________________________________
Respondent’s Mother’s name and address_________________________________________________
Other income(s) for parties (if applicable)____________________________________________
When and Where married
Date of separation__________________
Last marital domicile__________________________________________________________________
Are you Plaintiff or Defendant in the underlying divorce action?_______________________
Prothonotary’s Docket No.______________________________________________________________
When and how much was the Respondent’s last contribution for APL/Spousal
support?_______________________________________________________________________________
Are you receiving Public Assistance?( )Yes( )No;
#_______________
Dept. of Public Welfare
Did you ever file a complaint for support or APL in any court? (
) Yes
(
) No
If so, Where?
What is the status of that case?__________
_______________________________________________________________________________________
Reason for separation
_________________________________________________________________
Remarks _______________________________________________________________________________
Are you requesting medical support services?
___________________________________________
Medical Insurance Information: Complete this section as fully as possible at the time
of application.
Who insures the Petitioner for whom APL is requested?
Respondent
Petitioner
Respondent’s Insurance Information
Petitioner’s Insurance Information
Insurance Carrier:
Insurance Carrier:
Group/Policy/Agreement number:
Group/Policy/Agreement number:
List of names for those covered:
List of names for those covered:
_
Type of Coverage:
Type of Coverage:
(
)Medicare Part A
(
)Medicare Part A
(
)Medicare Part B
(
)Medicare Part B
(
)Dental coverage
(
)Dental coverage
(
)Vision coverage
(
)Vision coverage
(
)Major Medical coverage
(
)Major Medical coverage
(
)Hospital Plan only
(
)Hospital Plan only
(
)Basic Hospitalization/Physician
(
)Basic Hospitalization/Physician
(
)Drug/Prescription coverage/Plan
(
)Drug/Prescription coverage/Plan
PRESENT
(
)NO COVERAGE AVAILABLE AT PRESENT
(
)NO COVERAGE AVAILABLE AT
Date
Petitioner/Attorney Signature____________________________________________
----------------------Domestic Relations Office Use Below This Line-------------------
Date APL request received by DRS
DRO number_______________________
Docket number__________________________________________
Conference Information_________________________________________________________________
DATE MEDICAL INFORMATION IS FULLY COMPLETED AND VERIFIED
H.O./DRO worker inserting completion date
Date PC Data__________________
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