Fill and Sign the New Hampshire Petition Form

THE STATE OF NEW HAMPSHIRE SUPERIOR COURT County In the matter of PETITION FOR LEGAL SEPARATION 1. Your Name Date of Birth Residence Address Town/City County State 2. Spouse’s Name Date of Birth Residence Address Town/City County State 3. City and State where you and your spouse were married Date of marriage 4. You have been a resident of New Hampshire since 5. Children born to or adopted by you and your spouse either before or during the marriage: NAME DATE OF BIRTH NAME DATE OF BIRTH 6. To my knowledge, wife is is not pregnant 7. Please check one of the following regarding public assistance: No public assistance (AFDC/TANF) is now being or has within the last 6 months been provided, nor is medical assistance (Medicaid) presently being provided, for any minor child listed in paragraph 5 The N.H. Department of Health and Human Services is providing or has provided within the last 6 months public assistance (AFDC/TANF) and/or medical assistance (Medicaid) for any minor child. If this is checked, you must mail copies of this petition and the personal data sheet to the Department at: OCS Legal Office 6 Hazen Drive Concord, NH 03301 Case No. To be given by court SU-WWW-007 (4/98) The cause for legal separation is (check one or both): Irreconcilable differences have caused the irremediable breakdown of the marriage. Other grounds (fill in) By filing this petition, you are asking that the Court: A. Grant a legal separation. B. Equitably divide the personal property, retirement benefits, real estate, and debts. C If there are children listed in paragraph 5, or if wife is pregnant, issue orders concerning the custody, visitation, support, health insurance, and other matters relating to the minor child(ren). Check here if you are asking for physical custody or primary physical custody. D. Restore former name of wife or husband, if requested during the legal separation. E. Please check each request that applies: Issue orders concerning alimony (support for spouse). F. Grant any other orders which may be appropriate. 10. Temporary Orders , if issued, will be in effect until the legal separation is granted. Check here if you wish the court to issue temporary orders , and check what temporary orders you are requesting: The use of personal property and payment of debts. The use of family home. The custody, visitation, support, health insurance, and other matters relating to the child(ren) listed in paragraph 5. Alimony (support for spouse). __________________________________ _________________________________________ Date Signature (Sign in front of Notary Public /Justice of the Peace) _________________________________________ Attorney (if any) _________________________________________ Attorney’s address SU-WWW-007 (4/98) State of New Hampshire _______________________ County The person signing this petition appeared and signed it before me and took oath that the facts stated in this petition are true, to the best of his or her knowledge and belief, and that he/she has mailed copies of the petition and personal data sheet to OCS (if required under paragraph 7). ____________________________________ Date Notary Public/Justice of the Peace SU-WWW-007 (4/98)