Fill and Sign the Experienced Attorneys for Wisconsin Divorce Trialsdivergent Family Form

FORM CC-1421 (MASTER, PAGE ONE OF TWO) 07/19 { COURT USE ONLY } COURT USE ONLY COURT USE ONLY PETITION FOR PROCEEDING IN A NO -FAULT DIVORCE WITHOUT PAYMENT OF FEES OR COSTS Case No. .................................................................... COMMONWEALTH OF VIRGINIA VA.CODE § 17.1 -606 ........................................................................................................\ ............................ Circuit Court ........................................................................\ ....................................................... v. ........................................................................\ ....................................................... The undersigned petitioner request s the court to permit the petitioner to proceed in a no -fau lt divorce case under Virginia Code § 20- 91(A)(9) in this court without the payment of fees or costs and to have from all officers all needful services and process. In support of the petition, the petitioner state s that the following information is true: 1.[ ] I currently receive the following type(s) of public assistance in ........................................................................\ .................................................. CITY/COUNTY [ ] TANF $ ........................................... [ ] Medicaid [ ] Supplemental Security Income $ ................................................. [ ] SNAP (food stamps) $ .......................................... [ ] Other (specify type and amount) ................................................................... [ ] I currently do not receive public assistance. (If this box is checked, complete section 2, below. If not checked, proceed to section 3.) 2.Names and address of employer(s) for myself and spouse: Self ........................................................................\ ................................................................................................\ .............................................................................. Spouse ........................................................................\ ................................................................................................\ ........................................................................ NET INCOME: Self Spouse P ay peri o d (weekly, every seco nd week, twice monthly, monthly) ............................... ......................... .......................... Net take home pay (salary/wages, minus deductions required by law) ........................ $ ...................... .......................... Other income sources (please specify) ........................................................................\ ......................................................................................... $ ...................... .......................... TOTAL INCOME $ ...................... + .......................... = A ASSETS: Cas h o n hand ........................................................................\ ............................................................. $ ...................... .......................... Bank Accounts at: ........................................................................\ ................................................... $ ...................... .......................... Any other assets: (please specify) with a __________________________________________________________ value of ........................ $ ...................... .......................... Real estate – $ ______________________ $ ...................... .......................... NET VALUE with net _________________________________ value of ........................ $ ...................... .......................... YEAR AND MAKE Motor with net Vehicles _________________________________ value of ........................ $ ...................... .......................... YEAR AND MAKE Other Personal Property: (describe) ........................................................................\ .................. $ ......................... ............................. . TOTAL ASSETS $ ......................... + ............................. = B EXCEPTIONAL EXPENSES (Total Exceptional Expenses of Family) Medical Expenses (list only unusual and continuing expenses) ................................................................ $ ............................. Court -ordered support payments/alimony ........................................................................\ ................................. $ ............................. [ ] dedu cted from paycheck [ ] not deducted from paycheck Child -care paymen t s (e.g. day care) ........................................................................\ ............................................ $ ............................. Other (describe): ........................................................................\ ................................................................................ ........................................................................\ ................................................................................................\ ................... $ ............................. TOTAL EXPENSES $ ............................. = C COLUMN “A” plus COLUMN “B” minus COLUMN “C” equals available funds = ................. Number in household I have financial responsibility for, i ncluding myself. FORM CC-1421 (MASTER, PAGE TWO OF TWO) 07/19 3. ACKNOWLEDGEMENT I acknowledge that the foregoing is true and correct. I understand that the court cannot provide me with legal advice, and that it may be advisable to get ad vice from a lawyer. .................................................... ________________________________________________ ........................................................................\ ............. DATE SIGNATURE – PETITIONER PRINT NAME –PETITIONER ........................................................................\ ................................................................................................\ .............................................................................. RESIDEN CE ADDRESS OF PETITIONER _______________________ ........................................................................\ ............. SIGNATURE – PETITIONER PRINT NAME – PETITIONER ........................................................................\ ................................................................................................\ ............................................................................ RESIDEN CE ADDRESS OF PETITIONER Commonwealth/State of ........................................................................\ .. [ ] City [ ] County of ........................................................................\ The foregoing instrument was subscribed and sworn to/affirmed before me this .......................... day of ........................................................................\ ..................., ..................... by ........................................................................\ ................................................................................................\ ...................................................................... NAME OF APPLICANT __________ ______________________________________________ [ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY PUBLIC My commission expires: ........................................................... Registrati on No. ....................................................................... ORDER The petition is [ ] granted [ ] denied [ ] and the parties shall ........................................................................\ ................................................................................................\ ........... ........................................................................\ ................................................................................................\ ................................................... ........................................................................\ ................................................................................................\ ................................................... ........................................................................\ .................... _____________________________________________________________ DATE JUDGE