INSTRUCTIONS
UNCONTESTED DIVORCE PACKET WITHOUT CHILDREN
(for the Island of Kaua‘i)
In order to file a divorce action in the Family Court of the Fifth Circuit (on Kaua‘i), you must meet
certain limited residency requirements. You must have been domiciled or physically present on Kaua ‘i
continuously for at least 3 months prior to the filing of the Complaint for Divorce and either you or your spouse
must have been domiciled or physically present in the State of Hawai‘i continuously for at least 6 mont hs prior
to the filing of the Complaint for Divorce. The islands are divided into separate circuits. You must me et these
limited residency requirements and file you Complaint for Divorce in the correct circuit.
• First Circuit = O‘ahu -
• Second Circuit = Maui, La na‘i and Moloka‘i
• Third Circuit = Hawai‘i (Hilo and Kona Divisions)
• Fifth Circuit = Kaua‘i, Ni‘ihau
BEFORE YOU START.
Read through this entire instruction packet before you start to fill in the documents. This packet
includes instructions, information and forms needed to obtain an uncontested divorce. The Uncontested
Divorce (with children) Document Checklist contains information on how many copies of each document you
need to submit and who signs the document. The checklist also helps you see what documents you have
completed and which documents you still have to do.
The Divorce Decree in this packet contains provisions that covers most divorce situations. There may
be other terms or provisions necessary for your case. You are strongly urged to talk to an attorney to discuss
your legal rights and duties.
Most uncontested divorces are done by affidavit, with a Judge reviewing the documents you submit.
This means that neither you nor your spouse appear at a Court hearing if your documents are properly
completed and all the necessary steps have been followed. Therefore it is very important that you underst and
which documents are needed and what you must do before the Court will grant your divorce. If the Court has
any questions or concerns, you and your spouse may be required to appear at a hearing or submit more
documents.
It is important for you to realize that a divorce takes time. You will not be able to complete all your
divorce documents in one day. Be sure to read each document thoroughly and
and make sure you understand what the documents says. Do not sign any document you do not agree with or
you do not understand. Reprographics (03/10) 1 Uncontested Divorce Packet Without Children 5F-P-183
WHO CAN FILE FOR DIVORCE?
RevaComm 508 Certified
IF YOU NEED ASSISTANCE
The clerks of the Court are not allowed to give legal advice or assist you in the completion of the
divorce documents.
In accordance with the Americans with Disabilities Act, and other applicable stat e and federal laws, if
you require reasonable accommodations for a disability, please contact the ADA Coordinator at the F amily
Court Office at Phone no. 482-2314, FAX 482-2509, or TTY 482-2533.
Legal Assistance
If possible, you should seek the assistance of an attorney. Even if you cannot afford to have an attorney
to represent you for the whole divorce, you should try at least to talk to an attorney to discuss your legal rights
and duties.
You can check the Yellow Pages of the telephone book for names of attorneys or you may contact the
following organization for possible assistance.
HAWAI‘I STATE BAR ASSOCIATION
Lawyer Referral Service
Telephone: 240-0872
Website:
www.hawaiilawyerreferral.com
or www.hsba.org
The following organization offer assistance or self-help clinics to persons who fall within certa in income
brackets:
LEGAL AID SOCIETY OF HAWAI‘I
Kaua‘i Office
Intake Hotline Telephone: 245-7580, Monday through Friday, 9:00 AM to 11:30 AM
and 1:00 PM to 3:30 PM
If there have been incidents of Domestic Abuse, you may want to call the following organizations to
obtain assistance:
YWCA Kaua‘i
Telephone: 245-8404
Reprographics (03/10) 2 Uncontested Divorce Packet Without Children 5F-P-183
RevaComm 508 Certified
REFERENCE MATERIALS TO GUIDE YOU
- -
The Following materials located at the Kaua‘i Judiciary Complex Law Library, 3970 Ka ‘ana St., Lıhu‘e,
may assist you.
HAWAI‘I DIVORCE MANUAL (2005)
HAWAI‘I REVISED STATUTES
HAWAI‘I FAMILY COURT RULES
ON THE INTERNET Judiciary Web Page -
www.courts.state.hi.us
FILING FEES (Cash or Money Order/Cashier’s Check payable to:
CHIEF CLERK, FIFTH CIRCUIT)
DIVORCE (FC-D)
Initial Filing Fee: $100.00
Surcharge: + 25.00
Computer System Surcharge: + 50.00
TOTAL WITHOUT CHILDREN $175.00
Parent Education Surcharge: + 50.00
(If either party has children
from this marriage or any prior
relationship)
TOTAL WITH CHILDREN $225.00
Motions: No Fee
If you feel you cannot afford the filing fees, you may wish to contact the Legal Society of Hawai‘i
(Intake Hotline Telephone: 245-7580).
Reprographics (03/10) 3 Uncontested Divorce Packet Without Children 5F-P-183
RevaComm 508 Certified
FILE-STAMPING OR FILING YOUR DOCUMENTS:
You will need to get almost all of your documents “filed,” or “file-stamped,” at the court house. Look at
the Uncontested Divorce (with children) Documents Checklist for a summary of how many copies of each
document you will need to submit to Court. Documents are file-stamped by the Court at the following location
and during the following times.
LEGAL DOCUMENT SECTION -
3970 Ka ‘ana Street, Suite 207
-
Lı hu‘e, Kaua‘i, Hawai‘i 96766
Hours: 8:00 a.m. to 4:00 p.m.
Monday through Friday, excluding State/County holidays.
PLACING YOUR CASE ON THE COURT CALENDAR:
When you have completed all of your divorce documents, filed the necessary documents and serve your
spouse with the correct documents, you will be ready to have your case placed on the court calendar for judge’s
review. Refer to the Uncontested Divorce (without children) Documents Checklist for a summary of which
documents are required.
AFTER THE JUDGE REVIEWS YOUR DOCUMENTS:
Once your case is set on the uncontested divorce calendar, your documents will be reviewed by the
Court staff and the Judge. If the Judge grants your divorce and signs your Divorce Decree, the clerk will
contact you to pick-up your file-stamped certified copies of your Divorce Decree.
The clerk will contact you if your divorce is “DENIED” or is not fully granted. You must follow the
Judge’s instructions before your divorce can be completed.
http://www.hsba.org Reprographics (03/10) 4 Uncontested Divorce Packet Without Children 5F-P-183
RevaComm 508 Certified
Document Checklist For Uncontested Divorce (without children)
This is just a checklist. “You” are the Plaintiff, and “Spouse” is the Defendant.
A. FIRST: File these at the Legal Documents Branch of the Circuit Court: - -
Take these documents to the Legal Documents Branch of the Fifth Circuit Court (3970 Ka ‘ana Street, Lıhu‘e). A documents clerk will
file-stamp each document, keep the original for the Court’s file, and return the copies to you.
NAME OF DOCUMENT How Many Signed by Comments
❑ COMPLAINT FOR DIVORCE
❑
❑
❑
❑
❑
❑
RevaComm 508 Certified
Original
+
3 copies You
Filing this at the Legal Documents section of the Court starts the
divorce process. The Documents clerk will assign a Case Number.
Fill in this number on the other documents that you will file later.
SUMMONS TO ANSWER COMPLAINT Original
+
3 copies (Clerk
will
sign) Staple a copy behind each copy of the
Complaint for Divorce
before you take them to be filed.
MATRIMONIAL ACTION INFORMATION Original
+
1 copy You
INITIAL PRE-TRIAL ORDER Original
+
2 copy This Document need to be signed by the Judge and file-stamped
before you can start serving your spouse.
If your spouse will not sign an Appearance and Waiver, you must properly serve the Complaint for Divorce, Summons to Answer
Complaint on your spouse and file one of the following:
PROOF OF SERVICE Original
+
1 copy This document must be completed by the person who delivers the
Complaint for Divorce
, Summons to Answer Complaint, and
Initial Pre-trial Order to your spouse. It cannot be file-stamped
by the Documents clerk until the person who served the document
completes filing it out.
*Documents can be served by personal services (a list of personal
servers are located on the bulletin board located at the court
house). or by any responsible person who is over 18 years old,
and is not related to the Plaintiff or the Defendant.
OR
MOTION FOR SERVICE BY MAIL AND
AFFIDAVIT; ORDER FOR SERVICE
BY MAIL Original
+
2 copies You (signed
before a
notary
public) If your spouse lives off-island, you can send the
Complaint for
Divorce , Summons to Answer Complaint, and Initial Pre-trial
Order by certified, registered mail, return receipt requested. This
form asked the Court’s permission for you to do so. You must sign
this document before a notary public, and submit it to the Legal
Documents.
OR
MOTION FOR SERVICE BY
PUBLICATION; AFFIDAVIT;
OF PLAINTIFF; ORDER FOR
SERVICE BY PUBLICATION
(AND MAILING OF NOTICE) Original
+
2 copies You (signed
before a notary
public) If you are unable to locate your spouse for service, you will need
to publish a Notice of Hearing in the newspaper. This form asks
the Court’s permission to do so. You must complete the form and
sign the Affidavit before a notary public and submit it to Legal
Documents. You will be responsible to take a
filed copy of the
document to the advertising agency for publication.
Reprographics (03/10) 5 Uncontested Divorce Packet Without Children
5F-P-183
B. NEXT: Fill in the Case Number and file at the Legal Documents Branch: NAME OF DOCUMENT How Many Signed by Comments
❑ INCOME AND EXPENSE STATEMENT
OF PLAINTIFF Original
+
2 copies You
These documents must be dated 60 days current of the date you
place your case on the calendar.
❑ ASSET AND DEBT STATEMENT OF
PLAINTIFF (or BOTH PARTIES ) Original
+
2 copies You (and
Spouse if both
parties) You and your spouse may prepare and sign a joint Asset and
Debt Statement.
❑ INCOME AND EXPENSE STATEMENT
OF DEFENDANT Original
+
2 copies Spouse
If your spouse did not complete these forms, you must tell this
to the Court in you Affidavit of plaintiff , paragraph 10c.
❑ ASSET AND DEBT STATEMENT OF
DEFENDANT Original
+
2 copies Spouse
❑
❑
❑ APPEARANCE AND WAIVER
Original
+
1 copy Spouse
Your spouse must receive a file-stamped copy of the Complaint
for Divorce , Summons to Answer Complaint, and Initial Pre-trial
Order before
your spouse can sign this document.
❑
❑
❑
RevaComm 508 Certified
OR
PROOF OF SERVICE Original
+
1 copy Process
server To be completed by server before you can have it file-stamped.
OR
STATEMENT OF MAILING Original
+
1 copies You
If you served your spouse by mail, complete this document when
you receive the return receipt.
C. LAST: Fill in the Case Number and file at the Legal Documents Branch section: NAME OF DOCUMENT How Many Signed by Comments
AFFIDAVIT OF PLAINTIFF
(FOR UNCONTESTED DIVORCE) Original
+
1 copy You (Signed
before a notary
Public) This document is a sworn statement that you must sign before a
notary public. It requires that you provide various information and
dates. Do
not complete this document until the other documents
have been completed.
DIVORCE DECREE
(WITHOUT CHILDREN) Original
+
3 copies You
and
Spouse Your spouse’s signature is required if you are getting a divorce
by agreement (and your spouse has signed an
Appearance and
Waiver ).
CERTIFICATE OF MAILING Original
+
1 copy You
Proof to Court that Defendant was served copy of Divorce Decree.
Your divorce becomes final when the Divorce Decree is signed by the Judge and file-stamped. The clerk wi ll contact you when the
Decree is file-stamp or if it needs to be corrected.
Reprographics (03/10) 6 Uncontested Divorce Packet Without Children 5F-P-183
STATE OF HAWAI‘I FAMILY COURT
FIFTH CIRCUIT COMPLAINT FOR DIVORCE
CASE NUMBER
FC-D NO.
PLAINTIFF, (Full Name) ❑
❑
❑ ____
❑ ____
❑ ____
❑ ____
❑
❑ ❑ ❑
❑ ❑ ❑
❑
❑ ❑ ________________
❑
❑ ❑ ❑
❑
❑
❑
RevaComm 508 Certified
VS.
DEFENDANT. (Full Name) This document is prepared by
Plaintiff Attorney for Plaintiff
Name
Address
City, State, Zip Phone
I, the Plaintiff, in support of this Complaint for Divorce, allege:
l. Jurisdiction: I and/or my spouse, the Defendant, have lived or have been physically present in the State of Hawai‘i for a continuous
period of at least six (6) months and I have lived and/or been physically present on the Island of Kaua‘i for a continuous period of at least three (3) months immediately preceding this application.
2. Marriage: The parties (plaintiff and spouse) are lawfully married to each other.
3. Children:
a. ❑ The parties have no children together.
b. The parties have
(enter number) child(ren) under 18 together.
c. The parties have
(enter number) child(ren) 18 or older together, who are dependent on them for support.
d. The parties have
(enter number) child(ren) 18 or older together, who are not dependent on them for support.
e. Wife has
(enter number) child(ren) born during the marriage, not fathered by Husband.
f. Wife is pregnant.
4. Custody and Visitation: a. Legal custody of the minor child(ren) should be awarded to: Me, Plaintiff My spouse, Defendant Both parties jointly
b. Physical custody of the minor child(ren) should be awarded to:
Me, Plaintiff My spouse, Defendant Both parties jointly
c. The parent not awarded physical custody should have:
Reasonable visitation Supervised visitation
d. Child support should be awarded in accordance with the child support guidelines.
5. Division of Assets:
All assets my spouse and I own should be divided in a just and equitable way.
6. Division of Debts: All debts my spouse and I owe should be divided in a just and equitable way.
7. Spousal Support (Alimony):
a. I am entitled to an order that my spouse pay spousal support (alimony) to me.
b. My spouse isis not entitled to an order that I pay spousal support (alimony) to him/her.
8. Grounds:
Pursuant to HRS Section 580-41, I allege that the grounds for divorce are as follows (check one only): a. The marriage is irretrievably broken.
b. The parties have lived separate and apart for a period of two (2) or more years under a decree of separation from bed and board or under a decree of separate maintenance.
c. The parties have lived separate and apart for a continuous period of two (2) or more years immediately preceding the application, there is no reasonable likelihood that cohabitation will be resumed,
and it would not be harsh and oppressive to Defendant, or contrary to the public
interest, to grant a divorce on this ground on the complaint of Plaintiff.
It is requested of the Court:
That a decree be entered granting a divorce from the bonds of matrimony and granting the relief requested above, all as alleged and as may be appropriate and in accordance with the
evidence and the law, and other relief as the Court deems proper in this case.
I declare, under penalty of perjury, that the statements made herein are true and correct to the best of my knowledge, information and belief.
DATE PLAINTIFF’S SIGNATURE
Reprographics (08/09) COMPLAINT FOR DIVORCE 5F−P−186
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT SUMMONS
TO ANSWER COMPLAINT CASE NUMBER
FC-D NO.
PLAINTIFF, (Full Name) ❑
❑
RevaComm 508 Certified
VS.
DEFENDANT. (Full Name) This document is prepared by
Plaintiff Atty. for Plaintiff
Name Address
City, State, Zip Phone
TO THE DEFENDANT You are hereby summoned and required to serve a written answer to the attached Complaint within 20 days after
service of this Summons upon you, exclusive of the date of service.
Your written answer must be filed with the Chief Clerk of this Circuit at the following location or address.
A copy of your answer should also be served upon the Plaintiff ’s attorney, or in the event Plaintiff is not
represented by an attorney, upon the Plaintiff at the address shown on the Complaint.
CIRCUIT COURT OF THE FIFTH CIRCUIT KAUA‘I JUDICIARY COMPLEX -
3970 KA ‘ANA STREET, SUITE 207
-
LI HU‘E, HAWAI‘I 96766
If you fail to file your written answer within the 20-day time limit, further action may be taken in this cas e,
including judgment for the relief demanded in the Complaint, without further notice to you.
THIS SUMMONS SHALL NOT BE PERSONALLY DELIVERED BETWEEN 10:00 P.M. AND
6:00 A.M. ON PREMISES NOT OPEN TO THE PUBLIC, UNLESS A JUDGE OF THE
DISTRICT OR CIRCUIT COURTS PERMITS, IN WRITING ON THE SUMMONS,
PERSONAL DELIVERY DURING THOSE HOURS.
FAILURE TO OBEY THE SUMMONS MAY RESULT IN AN ENTRY OF A DEFAULT AND
DEFAULT JUDGMENT AGAINST THE PERSON SUMMONED.
DATE CLERK OF COURT
Reprographics (08/09) SUMMONS TO ANSWER COMPLAINT 5F−P−187
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT MATRIMONIAL ACTION
INFORMATION CASE NUMBER
FC-D NO.
PLAINTIFF
RevaComm 508 Certified
DEFENDANT PREPARED:
PLAINTIFF DEFENDANT ATTORNEY FOR PLAINTIFF ATTORNEY FOR DEFENDANT
NATURE OF CASE DIVORCE SEPARATION ANNULMENT
OTHER DATE FILED
ITEM WIFE HUSBAND
FULL NAME BIRTH OR MAIDEN NAME ADDRESS STREET, APT. NO. TOWN, STATE, ZIP COUNTY PHONE HOME WORK HOME WORK
SOCIAL SECURITY NUMBER (LAST FOUR DIGITS ONLY) XXX−XX- XXX−XX-
DATE OF BIRTH PLACE OF BIRTH (State or Country) RACE HIGHEST GRADE COMPLETED HAWAI‘I RESIDENT SINCE CIRCUIT RESIDENT SINCE PRIMARY EMPLOYER (Name and Address) JOB TITLE WORK SCHEDULE LENGTH OF SERVICE GROSS MONTHLY INCOME (All Sources) Primary Secondary Welfare Primary Secondary Welfare
DATE OF THIS MARRIAGE DATE
COUNTY / STATE
DATE OF SEPARATION NOT SEPARATED DATE
COUNTY / STATE
Reprographics (08/09) MATRIMONIAL ACTION INFORMATION 5F−P−188
MATRIMONIAL ACTION INFORMATION (Continued) CASE NUMBER
FC-D NO.
FROM
MONTH/YEAR TO
MONTH/YEAR TERMINATED BY
DIVORCE ANNULMENT DEATH STATE
WIFE’S PRIOR MARRIAGES
RevaComm 508 Certified
HUSBAND’S PRIOR MARRIAGES
CHILDREN: ALL CHILDREN OF EITHER PARTY FROM YOUNGEST TO OLDEST
CHILD’S FULL NAME M/F BIRTHDATE LEGAL
PARENT PRESENT
CUSTODY
(HUSBAND, WIFE OR OTHER) SCHOOL AND GRADE
INFORMATION REQUIRED FOR CUSTODY
CHILD(REN)’S PRESENT ADDRESS:
PLACES WHERE AND PERSONS WITH WHOM THE CHILDREN HAVE LIVED WITHIN THE LAST FIVE YEARS AND DATES ADDRESS CARETAKERS FROM
MONTH/YEAR TO
MONTH/YEAR
WIFE IS IS NOT PREGNANT. EXPECTED DELIVERY DATE: THE UNDERSIGNED SOLEMNLY AND SINCERELY DECLARES, UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF.
DATE SIGNATURE
Reprographics (08/09) MATRIMONIAL ACTION INFORMATION 5F−P−188
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT APPEARANCE AND WAIVER CASE NUMBER
FC-D NO.
PLAINTIFF,
(Full Name)
RevaComm 508 Certified
VS. DEFENDANT. (Full Name) This document is prepared by
❑ Plaintiff ❑ Defendant ❑Atty. for Plaintiff ❑Atty. for Defendant
Name Address
City, State, Zip Phone
I, the Defendant, acknowledge receipt of a filed copy of the Complaint and Summons in the above-entitled
action, submit myself to the Court’s jurisdiction, and have agreed with the Plaintiff on the matters set forth in
❑ a signed agreement incident to divorce.
❑ a form of Decree which I have approved by signature.
I consent to a hearing of the complaint by a judge at any time without further notice and without my
presence so long as the Decree issued incorporates the provisions I have approved. If such Decree is not
entered by the Court, I request to be notified.
I understand that I am not required to sign this paper and that by doing so I am permitting the Court without
opposition from me to proceed with the above-entitled matter at this time unless there is reason for t he Court to
alter our agreement.
❑I am not in the military service of the United States.
❑ I am in the military service of the United States, but I do not request a stay of proceedings herein, and
I do waive any rights I may have under the Soldiers’ and Sailors’ Civil Relief Act, 50 U.S.C. Sec. 521, et. seq.
DATE DEFENDANT’S SIGNATURE
Reprographics (08/09) APPEARANCE AND WAIVER 5F−P−189
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT PROOF OF SERVICE CASE NUMBER
FC-D NO.
PLAINTIFF, (Full Name) ❑
❑
❑ ❑
❑ ❑ ❑
❑
❑
❑ ___________________________________________
RevaComm 508 Certified
VS.
DEFENDANT. (Full Name) This document is prepared by
Plaintiff Attorney for Plaintiff
Defendant Attorney for Defendant
Name Address
City, State, Zip Phone
I served a certified copy of each document identified below by delivering to the following person(s):
PERSON(S) SERVED DATE TIME PLACE
DOCUMENTS SERVED
Complaint and Summons Initial Pre-trial Order Notice to Attend Kids First
Motion and Affidavit for Temporary Relief; Order to Show Cause for Temporary Relief
Motion and Affidavit for Order to Show Cause for Relief After Order or Decree; Order to Show Cause for Relief Afte r
Order or Decree
PLEASE EXPEDITE RETURN OF SERVICE TO FAMILY COURT
DATE POLICE OFFICER’S SIGNATURE BADGE ID NUMBER
DATE OTHER SERVING OFFICER’S SIGNATURE NAME OF SERVING OFFICER
❑ UNSERVED DOCUMENTS: I certify that, despite due and diligent search, I was unable to
locate the person to be served, and therefore the attached documents are being returned as
unserved.
Reprographics (08/09) PROOF OF SERVICE 5F−P−190
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT MOTION FOR SERVICE BY MAIL
AND AFFIDAVIT;
ORDER FOR SERVICE BY MAIL CASE NUMBER FC-D NO.
PLAINTIFF,
(Full Name)
❑
❑
RevaComm 508 Certified
VS.
DEFENDANT.(Full Name) This document is prepared by:
Movant Attorney for Movant
Name Address
City, State, Zip Phone
MOTION FOR SERVICE BY MAIL AND AFFIDAVIT
The undersigned party to this action moves, pursuant to HRS 580-3(c) and Hawai‘i Family Court Rule 4(e)(2), for an order
authorizing service by registered or certified mail. In support of this motion the undersigned states that to hi s/her best
information and belief the adverse party is outside the State and receives mail at the following a ddress:
MOVANT’S SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS DATE: NOTARY PUBLIC’S SIGNATURE STATE OF HAWAI‘I, FIFTH JUDICIAL CIRCUIT MY COMMISSION
EXPIRES:
ORDER FOR SERVICE BY MAIL
It appears that service by mail is appropriate and reasonable. IT IS HEREBY ORDERED that service he rein may be
made by forwarding certified copies of the
❑ Complaint ❑ Summons ❑ Initial Pre-Trial Order ❑ Notice to Attend Kids First Program
❑ Motion and Affidavit for Temporary Relief; Order to Show Cause for Temporary Relief
❑ Motion and Affidavit for Order to Show Cause and Relief After order or Decree; Order to Show Cause for Relief
After Order or Decree
❑ Income and Expense Statement; Asset and Debt Statement
❑ Other: _______________________________________________________________
_____________________________________________________________________ _____________________________________________________________________
and of this Order to the ❑ Plaintiff ❑ Defendant by registered or certified mail with return
receipt requested and a direction to deliver to addressee only and that actual receipt by the
❑ Plaintiff ❑ Defendant of the above document(s) sent in accordance with this Order shall
be equivalent to personal service by an authorized process server as of the date of receipt.
DATE JUDGE OF THE ABOVE-ENTITLED COURT
Reprographics (08/09) MOTION FOR SERVICE BY MAIL AND AFFIDAVIT;
ORDER FOR SERVICE BY MAIL 5F−P−191
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT STATEMENT OF MAILING
EXHIBIT “1” AND “2” CASE NUMBER FC-D NO.
PLAINTIFF,
(Full Name) ❑
❑
___________________________________
________________________________________________________________________________ ,
______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
RevaComm 508 Certified
vs.
DEFENDANT. (Full Name) This document is prepared by:
Plaintiff Attorney for Plaintiff
Name
Address
City, State, Zip Code Phone
I REPRESENT THAT I caused one certified copy each of the Complaint for Divorce; Summons to Answer Complaint;
and Motion for Service by Mail and Affidavit; Order for Service by Mail; and to be mailed by certified or registered mail, return receipt requested, restricted delivery to :
Defendant’s Name:
Defendant’s Address:
City, State, Zip Code:
Defendant
At the time of mailing, the receipt attached hereto as Exhibit “1” was postmarked and dated. Thereafter, the return
receipt attached as Exhibit “2” was received.
DATE PLAINTIFF’S SIGNATURE
Reprographics (08/09) STATEMENT OF MAILING; EXHIBIT “1” AND “2” 5F−P−192
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT STATEMENT OF MAILING
EXHIBIT “1” AND “2”
(continued) CASE NUMBER FC-D NO.
EXHIBIT 1
EXHIBIT 2
Reprographics (08/09) STATEMENT OF MAILING; EXHIBIT “1” AND “2” 5F−P−192
RevaComm 508 Certified
______________________________________________________________
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT CERTIFICATE OF MAILING CASE NUMBER FC-D NO.
PLAINTIFF,
(Full Name) ❑
❑
___________________________________________________________________________________
,
____________________________________________
______________________________________________________________________________________
________________________ ______________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________
_________________________________________________________
RevaComm 508 Certified
vs.
DEFENDANT. (Full Name) This document is prepared by:
Plaintiff Attorney for Plaintiff
Name
AddressCity, State, Zip Code
Phone
Comes now
herein and hereby certifies that on he/she caused to be mailed or
delivered to at his or her last known address. certified copy/copies of the
This certification is made pursuant to Rule 97 of the Hawai‘i Family Court Rules.
Dated:
Signature
Reprographics (08/09) CERTIFICATE OF MAILING 5F−P−193
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT INCOME AND EXPENSE STATEMENT
Plaintiff ❑
❑
❑
❑ ❑ ❑
_________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
_____________
________
___________
___________ ____________
____________ ____________
____________
____________
___________ _____________
____________ ____________
____________
____________
____________
____________
___________ ____________
_ _
___________
____________ ____________
_____________
RevaComm 508 Certified
Defendant CASE NUMBER
FC- NO.
PLAINTIFF, (Full Name)
VS.
DEFENDANT. (Full Name) This document is prepared by:
Plaintiff Defendant Atty. for Plaintiff Atty. for Defendant
Name Address
City, State, Zip Phone
Occupation: JOB TITLE
Employer:
Address:
Length of service: month/year.
Income Tax Withholding based on: dependents.
INCOME
Gross income. Paid: monthly, 2 times per month, every 2 weeks, weekly or other
Gross per pay period ...................................... $ Per month ............................... $
Payroll deductions per pay period: Fed. income tax ....................................... $
State income tax ...................................... $
FICA (Social Security) ............................
$
Union dues .............................................. $
a) Net per pay period ................... $ Per month ........ $
Other: Retirement/401K ................................... $
Credit Union .......................................... $
Direct Deposit ....................................... $
Income Assignments .............................. $
Support Payments .................................. $
Medical Insurance ................................. $
b) Take home per pay period ....... $Per month ........ $
Other regular monthly income, (rental income, 2nd job, interest, child support, welfare,
food stamps, and any other source.) Gross monthly receipt ............................. $
Taxes paid IRS and State on above .......... $
c) Total other income net ............................... $
Total Monthly Income (Add per month income from lines a and c above) $
Reprographics (08/09) INCOME & EXPENSE STATEMENT 5F−P−194
EXPENSES
Do not list expenses which are paid by payroll deduction.
Housing, expenses per month: rent, mortgage, agreement of sale ................................ $ ____________
____________
____________
____________
____________
____________
____________ ____________
____________
____________ ( _ )
____________ $ ____________
____________ $ ____________ ____________
____________
$
____________ $ ____________ ____________ ____________
____________ $
____________ $
____________ $ ____________ ____________ ____________ ____________ ____________
____________ $
____________ $
(_____________________) .................................. $ ____________ $
____________ $ ____________ ____________ ____________ ____________
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________
❑
RevaComm 508 Certified
insurance if not included above
.................................... $
Real Property taxes (if paid separately) ........................ $
Utilities, gas, water, elec., telephone etc. ...................... $
Transportation, expenses per month: Car payment, lease, rental ............................................ $
Insurance on vehicle .................................................... $
Maintenance (repairs) .................................................. $
Operating (gas, oil & tires) .......................................... $
Total Housing and Transportation expenses ..................................................................................... $
Debt service (all monthly payments, eg. credit cards, charges, finance company, personal loans) ...... $
Personal Expenses per month: Self Children No. Food ............................................................................... $
Clothing ......................................................................... $
Medical and Dental ........................................................ $
Laundry & Cleaning ....................................................... $
Personal articles ............................................................. $
Recreation (movies etc) .................................................. $
School (include food) ..................................................... $
Household ...................................................................... $
Bus (on monthly basis) ................................................... $
Other
Payment to others for dependent care ......................................................................................... $
Sub Totals .......................................................... $
Total Personal expenses ................................................................................ $
Grand Total expenses: Housing, Trans., Debt & personal ............................. $
Savings, : Income minus Expenses .......................................... $
Explain in detail where savings are invested, or if there is a , who provid es the funds to
maintain the level of spending indicated in this income and expense statement . (Use separate sheet if more space
is needed.)
CERTIFICATION
I hereby declare under the penalty of perjury that I have supplied the information used
in this Income and Expense Statement and have reviewed this statement and I certify
that the information is accurate, complete and correct.
DATE PLAINTIFF’S ❑ DEFENDANT’S SIGNATURE
Reprographics (08/09) INCOME & EXPENSE STATEMENT 5F−P−194
0.00
0.00
0
0.00
0
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT ASSET AND DEBT STATEMENT
❑
Plaintiff ❑ Defendant ❑ Both Parties CASE NUMBER
FC- NO.
PLAINTIFF, (Full Name)
VS.
DEFENDANT. (Full Name) This document is prepared by:
❑ Plaintiff ❑ Defendant ❑ ❑ Atty. for Plaintiff Atty. for Defendant
Name Address
City, State, Zip Phone
1. Cash (on hand or held by others for me) $ ______________________________________
2. CREDIT UNION ACCOUNTS:
Name Title (H,W,J*) Credit Balance Debt Balance
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ __________________ __________________
3.
BANK AND SAVINGS ACCOUNTS: (Include Trustee Accounts)
Company & Branch Type of Account Title (H,W,J) Current Balance
4. SECURITIES: (Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.)
Company Title (H,W,J) Date of Acquisition Cost Market Value Debt Owed Against
* H = Husband W = Wife
J = Joint
Reprographics (08/09) Page 1 of 3
ASSET AND DEBT STATEMENT 5F−P−195
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________ _____________________________ _____________________________
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5. VEHICLES: (Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.)
Year Make Title (H,W,J) Current Market Value Debt Owed Against
_____________________ ______________________ _________________ _______________________________________________ ___ __ ___
______________________ ______________________ __________________ _______________________ __ _ ____ _______________________
_____________________ _______________________ __________________ ________________________ ______________________ __ _ ___ _
_____________________ ______________________ __________________ _______________________ ______________________ ___ _ ___ __
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ _____________________________________________________________________________________________________
______________
6. REAL PROPERTY:
Address Fee or Lease Title (H,W,J) Date of
Acquisition Cost Current
Gross Value Total
Debt Owed
7. LIFE INSURANCE:
Company Person Insured Face Amount Beneficiary Title
(H,W,J) Cash Value Debt Owed
Against
8. RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS:
Employer or Company Title (H,W,J) Type of Plan Years in Plan
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
_______________________________________________________________________________________________ _
_______________________________________________________________________________________________ _ ___________________________________________________________________________________________________________________ ______________________________________Total
Value
9. ALL OTHER MAJOR ASSETS: (Furniture, Household Effects, Art, Stamps, Coins, Tools,
Equipment, Jewelry, Accounts Receivable, Investment Assets, Business Assets, Cem etery Plots or
Niches, Tax Refunds Due, etc.)
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
__________________________________________________________________________________________ ____
__________________________________________________________________________________________ ____
__________________________________________________________________________________________ ____ _______________________________________________________________
General Description Title (H,W,J) Estimated Gross Value Debt Owed Against
Reprographics (08/09) Page 2 of 3
ASSET AND DEBT STATEMENT 5F−P−195
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
RevaComm 508 Certified
STATE OF HAWAI‘I
FAMILY COURT FIFTH CIRCUIT ADMINISTRATIVE JUDGE’S
MEMORANDUM FC-
NO.
3970 K Street, Lı hu‘e, Hawai‘i 96766-1282 TEL (808) 482-2330
a ‘ana
Randal G.B. Valenciano
CHIEF JUDGE Calvin K. Murashige
FAMILY COURT JUDGE
DATE: July 21, 1999 (Updated July 2007)
TO: Fifth Circuit Judges, Attorneys, and Pro Se Litigants
FROM: The Honorable Randal G.B. Valenciano, Chief Judge
PROOF OF UNCONTESTED DIVORCE THROUGH AFFIDAVIT
Pursuant to Sections 580-5, H.R.S., the Family Court of the Fifth Circuit authorizes parties to an uncontested divorce to prove the case through an af�davit rather than by court appearance. Exact legal proof of every point is required in the af�davits. EFFECTIVE SEPTEMBER 1,1999 the following process will be used in af�davit only cases. 1. The Af�davit of Plaintiff must be �led with the documents clerk before the case is set. 2. The Af�davit of Plaintiff must contain legal proof of every point required (see the sample af�davit attached). Utilize the attached sample as a guide and only include paragraphs in the af�davit which apply to your case. Be sure to include any other information in the af�davit which is necessary or would be helpful to the judge. Such matters as circumstances justifying a variance from either child support guidelines
or matters affecting the partnership model for division of property must be stated or you risk rejection of the proposed decree.
3. If not previously �led, the following documents must be �led with the Af�davit: a. One or more of the following documents as proof of service: (1) Appearance and Waiver. The Appearance and Waiver must be �led in all non-default uncontested cases. It must be both hand-dated and signed by the Defendant after the
complaint has been �led. Family Court Rule 8(g) requires that the Appearance and
Waiver “shall be �led within a reasonable time before the date of hearing.” If the
Appearance and Waiver is not current within six months of the time of setting, the
Plaintiff must submit a Notice of Hearing to the Defendant and �le the Notice of Hearing with the Family Court clerk at the time the case is set.
(2) Proof of Service, Statement of Mailing or Af�davit of Publication:
(a) Upon Defendant. If no Appearance and Waiver is �led, Proof of Service of the Complaint by personal service, Statement of Mailing with a return receipt
signed by Defendant, or Af�davit of Publication must be provided if proceeding either by default or by agreement.
Reprographics (03/10) ADMINISTRATIVE JUDGE’S MEMORANDUM 5F-P-196
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10. PROPERTY HELD IN TRUST FOR OR BY THIRD PERSON/S: (Aside from Bank & Savings
Accounts Noted in paragraph 3)
Description Trustee/s Beneficiaries Value Debt Owed Against
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
11. ALL OUTSTANDING DEBTS: (Include those listed parts 2, 4, 5, 6, 7, 9, and 10 above, in
addition to all credit cards, charges, finance companies, and personal loans.)
Debtor Mo./Yr. Total Minimum Monthly
Creditor (H,W,J or Other) Security Debt Incurred Balance Owed Payment
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
Total Debt in Wife’s Name Alone: ______________________________________________________________________________
Total Debt in Husband’s Name Alone: _________________________________________________________________________
Total Debt in Joint Names: ______________________________________________________________________________________
CERTIFICATION
I hereby declare under the penalty of perjury that I have supplied the information used in this Asset and
Debt Statement and have reviewed this statement and I certify that the information is accura te, complete
and correct.
DATE ❑
PLAINTIFF’S ❑ DEFENDANT’S SIGNATURE
DATE ❑ PLAINTIFF’S ❑ DEFENDANT’S SIGNATURE
Reprographics (08/09) Page 3 of 3 ASSET AND DEBT STATEMENT 5F−P−195
RevaComm 508 Certified
i
S
p n
d
STATE OF HAWAI
‘I
FAMILY COURT FIFTH CIRCUIT ADMINISTRATIVE JUDGE’S
MEMORANDUM FC-
NO.
3970 Ka ‘ana Street, Lı hu‘e, Hawai‘i 96766-1282 TEL (808) 482-2330
(b) Upon Corporation Counsel. Proof of Service of the Complaint upon Family Support Division of Corporation Counsel must be �led if any party has a child who is a
recipient of Aid to Families with Dependent Children (AFDC).
b. Income and Expense Statement and Asset and Debt Statements of Plaintiff and Defendant:
Current �nancial statements must be �led by Plaintiff and Defendant if possible, as stated
below. Each party must hand-date and sign in black ink each of his/her statements. (1) Plaintiff. Plaintiff’s �led Income and Expense Statement and Asset and Debt Statement must re�ect �nancial information that is current within 60 days of the setting date (not the
hearing date) of the case. Plaintiff’s statements should re�ect all known assets held in the joint or sole names of the parties.
(2) Defendant. Plaintiff must submit to the counter clerk either: (a) Defendant’s �led Income and Expense Statement and Asset and Debt Statement current within 60 days of the setting of the case, or (b) A letter addressed to the Presiding Judge explaining why
current �nancial statements are not available.
c. Child Support Guidelines Worksheet (if applicable): Plaintiff must submit a �led copy of the
child support guidelines worksheet in all cases where the parties have minor and/or
dependent children. The worksheet must be signed by Plaintiff and Plaintiff’s attorney and
Defendant and Defendant’s attorney if possible.
d. Kids First Information Sheet (if applicable): Plaintiff must submit a Kids First Information Sheet in all cases where the parties have minor children between the ages of 6 and 17, re�ecting that both parties and applicable children have attended the Kids First Program.
e. Agreement Incident to Divorce (if applicable): All agreements must be �led, hand dated and
signed by both parties in black ink. The agreement should be signed before a notary or signature of counsel should appear on the agreement.
f. Paternity Judgment (if applicable): If any minor children born during the marriage are not
fathered by the husband, the case must be placed on the contested divorce calendar unless the paternity of the natural father has already been adjudicated in a paternity action. See Hawaii Divorce Manual, 5th ed., Section 7 for appropriate procedures.
g. Proposed Decree: A signed original decree and copies must be provided to the Family Court counter clerk.
ignatures: Stipulated decrees shall be signed by both parties and their attorneys. Each
arty must also hand-write the date in black ink next to his/her signature. If the decree
corporates an Agreement Incident to Divorce, only opposing counsel needs to sign the
egree “approved as to form.”
Reprographics (03/10) ADMINISTRATIVE JUDGE’S MEMORANDUM 5F-P-196
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RevaComm 508 Certified
STATE OF HAWAI‘I
FAMILY COURT FIFTH CIRCUIT ADMINISTRATIVE JUDGE’S
MEMORANDUM FC-
NO.
3970 Ka ‘ana Street, Lı hu‘e, Hawai‘i 96766-1282 TEL (808) 482-2330
h. Order for Income Assignment (if applicable): Plaintiff shall submit an original of the Order
for Income Assignment (OIA) and copies to the Family Court counter clerk together with
the decree. If no OIA is submitted because the obligator has no periodic income, or the parties have elected direct payments to the custodial parent, and the defendants of the obligor parent are not receiving public assistance bene�ts, this should be explained in the
Af�davit of Plaintiff. The Degree should nevertheless order that child support will be paid by
OIA as soon as the obligor receives periodic income, and should further require the obligor
to notify the Child Support Enforcement Agency in writing of the name and address of the employer or other payor as soon as he receives such income.
i. Order Granting Motion: If Plaintiff is proceeding by default, a �led copy of the Order Granting
Motion for Default must be submitted in all af�davit cases at the time the case is set. Otherwise, a hearing on a motion for default should be scheduled at the time of the uncontested divorce and the Notice of Motion will re�ect the same date and time as the uncontested divorce.
4. In the af�davit only cases, the case �le including all documents will be reviewed by the
assigned judge on or about the date of the hearing. The judge, after a hearing without
appearances, will note the disposition on the court’s calendar as follows: a) granted; b) decree to be resubmitted (with corrections); or c) court hearing with appearances required
Original and Copies of the rejected decrees will be returned to the attorneys via attorney’s
jacket or to Plaintiff via mail along with Noti�cation of Case Status/De�ciency notice. Corrections to be completed before resubmitting documents back to the Legal Documents Branch.
Reprographics (03/10) ADMINISTRATIVE JUDGE’S MEMORANDUM 5F-P-196
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RevaComm 508 Certified
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT AFFIDAVIT OF PLAINTIFF
(FOR UNCONTESTED DIVORCE) CASE NUMBER
FC-D NO.
PLAINTIFF,
(Your Full Name)
VS.
DEFENDANT.
(Your Spouse’s Full Name) This document is prepared by
❑ Plaintiff ❑ Attorney for Plaintiff
Name Address
City, State, Zip Phone
STATE OF HAWAI‘I
COUNTY OF KAUA‘I ) )
) SS.
Plaintiff in the above-entitled action, being first duly sworn on oath, deposes and says that:
1. Plaintiff ’s full name and address is:
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
2. Legal Repr esentation
:
2a. ❑
Plaintiff is representing him/herself.
2b. ❑ Plaintiff is represented by the attorney named above.
3. Service of process on Defendant was made by :
3a.
❑ Personal Service: A Proof of Service or Affidavit of Service has been filed showing that the Defendant
was personally served with the Complaint and Summons on _______________________ by a person
authorized to serve of legal documents. (Mo/Day/Yr)
3b. ❑
Certified or Registered Mail: The Complaint and Summons was served upon Defendant by certified or
registered mail. A Statement of Mailing or Affidavit of Mailing and an original return receipt s igned by the
Defendant on ________________ have been filed. Plaintiff recognizes Defendant’s signature on the return
receipt. (Mo/Day/Yr)
3c. ❑
Appearance and Waiver: Defendant acknowledged receipt of a filed copy of the Complaint and Summons
and signed an Appearance and Waiver on ______________________. Plaintiff recognizes Defendant’s signature on the Appearance and Waiver. (Mo/Day/Yr)
3d. ❑
Publication: The Affidavit of Publication was filed on _________________.
(Mo/Day/Yr)
4. ❑
Default .
4a. ❑
More than twenty (20) days have passed since the service of the Complaint
and Summons on the Defendant. No responsive pleading has been filed.
Neither Plaintiff nor Plaintiff ’s attorney has received any communication
from Defendant or Defendant’s attorney concerning this case since the Com-
plaint was served.
4b. ❑
An order granting the Motion for Entry of Default was filed on___________________.
(Mo/Day/Yr)
Reprographics (08/09) Page 1 of 4 AFFIDAVIT OF PLAINTIFF (UDA) 5F−P−197
RevaComm 508 Certified
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT AFFIDAVIT OF PLAINTIFF
(FOR UNCONTESTED DIVORCE) PAGE TWO CASE NUMBER
FC-D NO.
5. Jurisdiction : (Check all that apply)
5a. ❑
Plaintiff had been domiciled or physically present on the Island of Kaua‘i for a continuous period of at least
3 months prior to the filing of the Complaint for Divorce.
❑
❑
_______________________________ _______________________________ . (City) (State)
_______________________________ .
(Mo/Day/Yr)
___________________________ ________________________
_____________________________________ . (City)
(State)
(Mo/Day/Yr)
__________________________________________________________________________________________ __________________________________________________________________________________________
❑ __________________________ .
(Mo/Day/Yr)
❑
_______________________.
(Mo/Day/Yr)
❑
_______________________________________________________________________________________ _______________________________________________________________________________________
❑
❑
❑
__________________________________________________________________________________________ .
❑ ❑
__________________________________________________________________________________________ .
❑
❑
____________________
RevaComm 508 Certified
5b. Plaintiff had been domiciled or physically present in the State of Hawai‘i for a continuous period of at le ast
6 months prior to the filing of the Complaint for Divorce.
5c. Defendant had been domiciled or physically present in the State of Hawai‘i for a continuous period of at
least 6 months prior to the filing of the Complaint for Divorce.
6. Defendant resides in (city, state) ,
7. The parties were married on
8. The parties last lived together in (city , state) , on
9. Plaintiff believes that the marriage is irretrievably broken because:
10. Financial statements :
10a. Plaintiff signed Income and Expense and Asset and Debt Statements on
T
o the best of Plaintiff ’s knowledge there have been no substantial
changes in Plaintiff ’s financial circumstances since that date.
10b. Defendant signed Income and Expense and Asset and Debt Statements on
Plaintiff recognizes Defendant’s signature on said documents.
10c. Defendant’s Income and Expense Statement and Asset and Debt Statement are not filed beca
use:
1 1. Plaintiff has carefully reviewed the proposed decree and agrees to the alimony, division of property and othe r
provisions as provided in the proposed decree.
12. Plaintiff signed the proposed decree.
Plaintiff recognizes Defendant’s signature on the decree.
13. Wife wishes to resume the use of her birth surname former married name and be known as:
14. Husband wishes to resume the use of his birth surname former married name and be known as:
15. Language Comprehension :
15a. Plaintiff fully understands the English language.
15b. Although Plaintiff does not fully comprehend written English, this document has been explained to him/
her by and based on that explanation Plaintif
f understands this document.
Reprographics (08/09) Page 2 of 4 AFFIDAVIT OF PLAINTIFF (UDA) 5F−P−197
STATE OF HAWAI‘I FAMILY COURT FIFTH CIRCUIT AFFIDAVIT OF PLAINTIFF
(FOR UNCONTESTED DIVORCE)
PAGE THREE CASE NUMBER
FC-D NO.
16. Plaintiff requests that the court grant this divorce and enter the decree without his/her appearanc e in court.
17. Plaintiff has read this document and signs it voluntarily and without coercion and duress and not because he /she
was told to sign it.
18. Pregnancy :
18a. ❑ Wife is not pregnant.
18b. ❑
Wife is pregnant and her expected date of delivery is _______________. Husband ❑ is ❑ is not the father
of said child. (Mo/Day/Yr)
19. Child(ren) :
19a. ❑
Plaintiff and Defendant have no children together.
19b. ❑ The parties have ______ children together. The complete name and birthdate of each are listed as foll ows
from the oldest to the youngest child (including adult child(ren)):
Name Date of Birth
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (Mo/Day/Yr)
(Mo/Day/Yr)
(Mo/Day/Yr)
(Mo/Day/Yr)
(Mo/Day/Yr)
(Mo/Day/Yr)
19c. ❑
There is/are child(ren) conceived during the marriage fathered by someone other than husband. Their
name(s) and date of birth is/are listed as follows:
Name Date of Birth Judgment of Paternity entered
_____________________________________________________________
_____________________________________________________________ (Mo/Day/Yr) ❑
Ye s
(Mo/Day/Yr) ❑
No
❑ Ye s ❑ No
20. Prior or Pending Custody Proceedings :
20a. ❑ I have not participated in any capacity in any law suit or proceeding in any state concerning custody of any
of the minor children of the Plaintiff and Defendant together. I have no information of any pending custody
proceeding or of any person not a party to this proceeding who has physical custody or claims to have
custody or visitation rights concerning any minor children of the Plaintiff and Defendant together.
20b. ❑
Prior court case involving the subject children:
Case Name:
Case Number:
________________________________________________________________________
____________________________________________________________________
___________________
__________________
_______________________________________
