Fill and Sign the Separation 497321946 Form

STATE OF NEW YORK COUNTY OF ______________________ ______________________________ , Plaintiff, Index No. _______________ VS. MEMORANDUM OF SEPARATION AGREEMENT ______________________________ , Defendant, 1. The names and address of each of the parties: HUSBAND WIFE ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 2. The date of the marriage of the parties: ______________________________ at ______________________________ , New York. 3. The date of the Agreement of Separation: _______________________ , 20 _____ . 4. The date of the subscription and acknowledgement of said Agreement of Separation: (a) By the Husband: ______________________ , 20 _____ (b) By the Wife: ______________________ , 20 _____ Dated: _______________________ , New York _________________________________ _________________________________ Wife _________________________________ Husband State of New York, County of ____________________ , ss.: On the _____ day of __________________ , 20 _____ , before me, the undersigned, personally appeared ______________________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her individual capacity, and that by her signature on the instrument, the individual, or the person upon behalf of whom the individual acted, executed the instrument. ___________________________________ Notary Public State of New York, County of _______________________ , ss.: On the _____ day of __________________ , 20 _____ , before me, the undersigned, personally appeared ______________________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her individual capacity, and that by her signature on the instrument, the individual, or the person upon behalf of whom the individual acted, executed the instrument. ___________________________________ Notary Public