Appendix V - Family Part Case Information Statement Form Page 2
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10Part A - Case Information:
Issues in Dispute:
Date of Statement
Cause of Action
Date of Divorce, Dissolution of Civil
Custody
Union or Termination of Domestic
Parenting Time
Partnership (post-Judgment matters)
Alimony
Date(s) of Prior Statement(s)
Child Support
Equitable Distribution
Your Birthdate
Counsel Fees
Birthdate of Other Party
Anticipated College/Post-
Date of Marriage, or entry into Civil Union
Secondary Education
or Domestic Partnership
Expenses
Other issues (be specific)
Date of Separation
Date of Complaint
Does an agreement exist between parties relative to any issue?
Yes
No.
If Yes, ATTACH a copy (if written) or a summary (if oral).
1. Name and Addresses of Parties:
Your Name
Street Address
City
State/Zip
Other Party’s Name
Street Address
City
State/Zip
2. Name, Address, Birthdate and Person with whom children reside:
a. Child(ren) From This Relationship
Child’s Full Name
Address
Birthdate
Person’s Name
b. Child(ren) From Other Relationships
Child’s Full Name
Address
Birthdate
Person’s Name
Part B - Miscellaneous Information:
1. Information about Employment (Provide Name & Address of Business, if Self-employed)
Name of Employer/Business
Address
Name of Employer/Business
Address
2. Do you have Insurance obtained through Employment/Business?
Yes
No.
Type of Insurance:
Medical
Yes
No;
Dental
Yes
No;
Prescription Drug
Yes
No;
Life
Yes
No;
Disability
Yes
No
Other (explain)
Is Insurance available through Employment/Business?
Yes
No
Explain:
3. ATTACH Affidavit of Insurance Coverage as required by Court Rule 5:4-2 (f) (See Part G)
Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V)
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