Petition For Dissolution Of Marriage Form Page 3
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415. The following people are not parties in this matter, but have physical custody of the child(ren) or claim rights
of parental responsibilities, legal custody or physical custody, or visitation/parenting time with the child(ren).
Identify name and address of those persons, if any.
Full Name of Person
Address (Street, City/State, Zip Code)
16. Required Notice of Human Services Involvement.
The parents or dependent child(ren) listed on this Petition has/have received within the last five years, or
is/are currently receiving benefits or public assistance from the state Department of Human Services or the
.
County Department of Social Services
No
Yes If your answer was Yes, complete the following:
Name of Person Receiving Benefit
Name of County and State
Case Number
Month/Year
17. Required Notice of Prior Protection/Restraining Orders.
Have any Temporary or Permanent Protection/Restraining Orders to prevent domestic abuse or any Criminal
Mandatory Protection/Restraining Orders (MRO) or Emergency Protection Orders been issued against either
party within two years prior to the filing of this Petition?
No
Yes
If your answer was Yes, complete the following:
The
Protection/Restraining
Order
was
Temporary
Permanent
MRO
and
issued
against
______________________________ in a
Municipal Court
County Court
District Court in the County of
______________, State of ______________, in case number _______________ on ______________ (date).
What was the subject matter of the Protection/Restraining Order or Emergency Protection Order?
18. Notice of Existing Case with Child Support Enforcement (CSE)
The parents have filed a case with CSE?
No
Yes If Yes, identify the case number: _____________
19. I/We ask that the Court enter orders regarding the
status of the marriage,
best interests of the child(ren),
maintenance (spousal support)
child support,
division of property and debts,
attorney fees and
costs, if appropriate,
restoration of the previous name of a party,
and any other necessary orders.
20. The
Petitioner
Co-Petitioner requests that the Court restore his/her prior full name to
______________________________________.
PETITION FOR: DISSOLUTION OF MARRIAGE LEGAL SEPARATION
JDF 1101
R11/10
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