Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 1 of 11 Form No. PL-00 Effective 10-01-201Name: Address: Telephone: In Pro Per THE SUPERIOR COURT OF CALIFORNIA IN AND FOR THE COUNTY OF PLACER In Re Matter/Marriage of: ) Case No. ) ) PETITIONER222S Petitioner: ) RESPONDENT222S ) STATEMENT OF ISSUES and ) AND CONTENTIONS ) Settlement Conference Respondent: ) Date: ) ) Trial or Long Cause ) Date: PRELIMINARY INFORMATION 1)Petitioner : Name D.O.B. Present Employer Gross Monthly Income $ 2)Respondent : Name D.O.B. Present Employer Gross Monthly Income $ 3)Date of Marriage American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 2 of 11 Form No. PL-00 Effective 10-01-201 Date of Separation Length of Marriage 4)Issues to be considered by the Court (check those that apply): Dissolution of the Marriage Child Custody Child Support Spousal Support Property Division and Equalization Assignment of Debts Other (specify) DISSOLUTION OF MARRIAGE (Complete if you are requesting dissolution of marriage) 5)When was the Respondent served with the Summons and Petition for Dissolution? (Date) CHILDREN OF THE RELATIONSHIP 6)Provide the following information regarding minor children of the relationship:Name Date of Birth Age 7)In Present Custody of (Petitioner / Respondent / Other) American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 3 of 11 Form No. PL-00 Effective 10-01-201 EXISTING ORDERS FOR CUSTODY AND SUPPORT (Complete if child custody or child support is in issue) 8)Is there presently an order for child custody in effect? a) Yes No 9)If yes, list existing child custody orders: Name of Child Date of OrderParty Having Custody Party Having Visitation 10)Is there presently an order for payment of child support?a) Yes No 11)If yes, list existing child support orders: Date of Order Type of Order/Amount Party to Whom Payable AGREEMENTS BETWEEN THE PARTIES (Complete in all cases) 12)Do you and the other party have any agreements concerning child custody or property or debts to beawarded to a party? a) Yes No b)If yes, list and describe each agreement: American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 4 of 11 Form No. PL-00 Effective 10-01-201 CHILD CUSTODY (Complete if child custody or child support is in issue) 13)Describe the child custody/visitation arrangements presently being followed by you and the otherparent: 14)Have the parents been to custody mediation? Yes No 15)If yes, has the report been completed? Yes No If the report has not been completed, when do you think it will be completed? (date) What is the date of the completed report and recommendation? (date) What custody/visitation arrangement is recommended by the Mediator222s Report? (Briefly describe): 16)Describe the custody arrangement you want the court to order at the present time (check theappropriate box): a) Remain the same. b) Adopt Mediator222s report dated: c) Other (describe): American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 5 of 11 Form No. PL-00 Effective 10-01-201 SEPARATE PROPERTY AND DEBTS (Complete if Property Division is an issue) 17)Does either party presently have property or debts which are the party222s separate property? Yes No 18)If yes, list each item of property and debt, and the party that property or debt belongs to:Description of Item/Debt Party to Whom it Belongs 1. 2. 3. 4. 5. COMMUNITY PROPERTY AND DEBTS (Complete if Property Division is an issue) 19)Property owned by the Parties:(List the property owned by you and the other party) Description of Item Present Value Who Has It (H or W) 1. 2. 3. 4. 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 6 of 11 Form No. PL-00 Effective 10-01-201 20)Shared Debts of the Parties:(List the debts for which you and the other party are liable) Creditor Name 226 Purpose of Debt Amount Owing 1. $ 2. $ 3. $ 4. $ 5. $ 21)Has either party made payments after your separation on debts shared by the parties? Yes No 22)If yes, list all payments on shared Debts of the Parties: Creditor Name 226 Date of Payment Amount Paid 1. $ 2. $ 3. $ 4. $ 5. $ FUNDS HELD BY OTHERS (Complete if Property Division is an issue) 23)Does any firm, business, or other entity have money or property in which either party presently hasan interest (e.g., life insurance policies, deposit accounts)? Yes No 24)If yes, list each item of property and the party who presently has the property, and describe yourinterest in the property: American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 7 of 11 Form No. PL-00 Effective 10-01-201 25)Does either party have an interest in a retirement plan, profit sharing or pension plan? Yes No 26)If yes, list the business, agency or employer who maintains the plan, and describe the party222s interestin the plan (e.g., party222s employer, party is receiving benefits from plan): TRACING (Complete if Property Division is an issue) 27)Was an item of property acquired by you and the other party using money or other property whichwas the sole property of just one of you? Yes No 28)If yes, list each item of property and describe how the property was acquired and what money orproperty belonging to just one party was used in acquiring the property described. (Example: a car owned before marriage was traded in to buy the car both parties now own):Describe in detail the circumstances: American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 8 of 11 Form No. PL-00 Effective 10-01-201 PROPOSAL FOR DIVISION OF PROPERTY AND DEBTS (Complete if Property Division is an issue) 29)Proposed Division of Property and Debts: Description of Item Award to H Award to W (list value of item in space) 1. 2. 3. 4. 5. 6. 7. 8. 30)What is the total value of the property you propose the court should award? 226to Petitioner $226to Respondent $ 31)What is the total amount of the parties222 debts you propose the court should award? 226to Petitioner $226to Respondent $ CURRENT INCOME AND EXPENSES (Complete in all cases) 32)Attach a completed Income and Expense Declaration which has current income and expense information for you. SPOUSAL SUPPORT (Complete if Spousal Support is in issue) 33)Is there presently an order for payment of spousal support? a) Yes (complete b., c. and d.) No (go on to 34) American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 9 of 11 Form No. PL-00 Effective 10-01-201 b)Payable by which party? to which party? c)How much per month? (amount) d)Date the order was issued: (date) 34)Future Spousal Support: a)Should one Party pay Spousal Support to the other Party? Yes No b)Why / why not? CHILD SUPPORT (Complete in all cases where child custody or child support is in issue) 35)Is there presently an order for payment of child support? a) Yes (complete b., c. and d.) No (go on to 36) b)Payable by which party? to which party? (party name, or district attorney) c)How much per month? (amount) d)Date the order was issued: e)Is current or past due support being collected by the Department of Child Support Servicesor the District Attorney222s Family Support Division for any county? No Yes, for the following county/ies: American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 10 of 11 Form No. PL-00 Effective 10-01-201 36)Does either party presently pay for day care for work?a) Yes No b)If yes, what is the monthly cost of day