NAME *

First Name

Last Name

ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHONE

(###)

###

####

DATE OF BIRTH

MM

DD

YYYY

ARE YOU IN A NEW RELATIONSHIP?

No

Yes, but he/she lives elsewhere

Yes, and he/she lives with me

DESCRIBE YOUR ROLE IN THE MARRIAGE.

I was a homemaker. I did not work.

I worked full time to support the family.

I did odd jobs to help out.

We both worked and behaved as equals.

Other

NAME *

First Name

Last Name

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DATE OF BIRTH

MM

DD

YYYY

DESCRIBE THIS PERSON'S ROLE IN THE MARRIAGE.

He/she was a homemaker. Did not work.

He/she was the primary bread winner. Worked fulltime.

He/she worked odd jobs to help out.

He/she was my equal. We both worked.

He/she did not work or help out.

Other

DATE MARRIED

If you were not married, then put the date you started dating.

MM

DD

YYYY

DATE SEPARATED

This should be the date you and the other party officially stopped living together in the same household.

MM

DD

YYYY