Fill and Sign the State of New York County of Supreme Court Vs Form

STATE OF NEW YORK COUNTY OF______________________ ______________________________ , Plaintiff, Index No._______________ VS. ______________________________ ,MEMORANDUM OF Defendant, SEPARATION AGREEMENT 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 Agre ement 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 n ame is subscribed to the within instrument and acknowledged to me that she executed the same in h er individual capacity, and that by her signature on the instrument, the individual, or the pe rson 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 n ame is subscribed to the within instrument and acknowledged to me that she executed the same in h er individual capacity, and that by her signature on the instrument, the individual, or the pe rson upon behalf of whom the individual acted, executed the instrument. ___________________________________ Notary Public