American LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI217IFAMILY COURTFIRST CIRCUITAFFIDAVIT OF PLAINTIFF(FOR UNCONTESTED CIVIL UNION DIVORCE)CASE NUMBERFC-CU No.This document is prepared by:002Plaintiff002Attorney for PlaintiffPLAINTIFF,(Your Full Name)Namevs.AddressCity, State, ZipDEFENDANT(Your Partner220s Full Name)PhoneSTATE OF HAWAI217I CITY AND COUNTY OF HONOLULU)))SS.Plaintiff in the above-entitled action, being first duly sworn on oath, deposes and says that:1.Plaintiff220s full name and address is: 2.Legal Representation:2a.002Plaintiff is representing himself/herself.2b.002Plaintiff is represented by the attorney named above.3.Service of process on Defendant was made by: 3a.002 Personal Service: A Proof of Service or Affidavit of Service has been filed showing that the Defendantwas personally served with the Complaint and Summons on by a person authorizedto serve legal documents.(Month/Day/Year)3b.002 Certified or Registered Mail: The Complaint and Summons was served upon Defendant by certifiedor registered mail. A Statement of Mailing or Affidavit of Mailing and an original return receipt signed bythe Defendant onhave been filed. Plaintiff recognizes Defendant220s signature onthe return receipt.(Month/Day/Year)3c.002 Appearance and Waiver: Defendant acknowledged receipt of a filed copy of the Complaint and Summonsand signed an Appearance and Waiver on. Plaintiff recognizes Defendant220ssignature on the Appearance and Waiver.(Month/Day/Year)3d.002 Publication: The Affidavit of Publication was filed on.FOR COURT USE ONLY(Month/Day/Year)4.002Default4a.002More than twenty (20) days have passed since the service of the Complaintand Summons on the Defendant. No responsive pleading has been filed.Neither Plaintiff nor Plaintiff220s attorney has received any communication fromDefendant or Defendant220s attorney concerning this case since the Complaintwas served.4b.002An order granting the Motion for Entry of Default was filed on.(Month/Day/Year)In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonableaccommodation for a disability, please contact the ADA Coordinator at the Office of the Chief Administrator at PHONE NO.954-8200, FAX954-8212, or TTY 539-4853 at least ten (10) working days prior to your hearing or appointment date.Please call Ho217okele, 002003004005006004007btHelp Desk, at 954-8290, if you have any questions about how to fill out this form.FC-Adm 12/11Page 1 of 4 PagesCUDA AFFIDAVIT OF PLAINTIFF005 Reprographics(01/12)1F1F-P-841American LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI217IFAMILY COURTFIRST CIRCUITAFFIDAVIT OF PLAINTIFF(FOR UNCONTESTED CIVIL UNION DIVORCE)Page 2 of 4 PagesCASE NUMBER FC-CU No. 5.Jurisdiction: (Check all that apply)5a.002Plaintiff was domiciled or physically present on the island of O217ahu for a continuous period of at least3 months prior to the filing of the Complaint for Civil Union Divorce.5b.002Plaintiff was domiciled or physically present in the State of Hawai217i for a continuous period of at least6 months prior to the filing of the Complaint for Civil Union Divorce.5c.002Defendant was domiciled or physically present in the State of Hawai217i for a continuous period of at least6 months prior to the filing of the Complaint for Civil Union Divorce.6.Defendant resides in (city, state),.(City)(State)7.The parties entered into a valid civil union on.(Month/Day/Year)8.The parties last lived together in (city,state),on.(City)(State)(Month/Day/Year)9.Plaintiff believes that the marriage is irretrievably broken because: 10.Financial statements:10a.Plaintiff signed Income and Expense and Asset and Debt Statements on(Mo./Day/Yr.)To the best of Plaintiff220s knowledge there have been no substantial changes in Plaintiff220s financialsince that date.10b.002Defendant signed Income & Expense and Asset & Debt Statements on(Mo./Day/Yr.)Plaintiff recognizes Defendant220s signature on said documents.10c.002Defendant220s Income & Expense and Asset & Debt Statements are not filed because:11.Plaintiff has carefully reviewed the proposed decree and agrees to the alimony, division of property and otherprovisions as provided in the proposed decree.12.Plaintiff signed the proposed decree. 002Plaintiff recognizes Defendant220s signature on the decree.13.002Plaintiff wishes to resume the use of his/her 002birth002former married name and be known as:14.002Defendant wishes to resume the use of his/her002birth002former married name and be known as: 15.Language Comprehension:15a.002Plaintiff fully understands the English language.15b.002Although Plaintiff does not fully comprehend written English, this document was explained to him/herby and based on that explanation Plaintiff understands this document.16.Plaintiff requests that the court grant this civil union divorce and enter the decree without his/her appearancein court.17.Plaintiff has read this document and signs it voluntarily and without coercion and duress and not becausehe/she was told to sign it. FC-Adm 12/11Page 2 of 4 PagesCUDA AFFIDAVIT OF PLAINTIFFAmerican LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI217IFAMILY COURTFIRST CIRCUITAFFIDAVIT OF PLAINTIFF(FOR UNCONTESTED CIVIL UNION DIVORCE)Page 3 of 4 PagesCASE NUMBERFC-CU No. 18.Pregnancy:18a.002Plaintiff002Defendant is not pregnant.18b.002Plaintiff is pregnant and her expected date of delivery is and Defendant 002is002is not the father of said child.(Month/Day/Year)18c.002Defendant is pregnant and her expected date of delivery is and Plaintiff 002is002is not the father of said child.(Month/Day/Year) 19.Child(ren):19a.002Plaintiff and Defendant have no children together. 19b.002Plaintiff has not adopted Defendant220s child(ren).19c.002Defendant has not adopted Plaintiff220s child(ren).19d.002The parties have children together. The complete name and birthdate of each are listed asfollows from the oldest to the youngest child (including adult child(ren)): NameDate of Birth(Mo./Day/Yr.)(Mo./Day/Yr.)(Mo./Day/Yr.)(Mo./Day/Yr.)(Mo./Day/Yr.)19e.002There is/are child(ren) conceived during this civil union fathered by someone other than myname(s) and date of birth is/are listed as follows: NameDate of BirthJudgment of Paternity entered (Mo./Day/Yr.)002Yes002No(Mo./Day/Yr.)002Yes002No 20.Prior or Pending Custody Proceedings:20a.002I have not participated in any capacity in any law suit or proceeding in any state concerning custodyof any of the minor children of the Plaintiff and Defendant together. I have no information of anypending custody proceeding or of any person not a party to his proceeding who has physical custodyor claims to have custody or visitation rights concerning any minor children of the Plaintiff andDefendant together.20b.002Prior court case involving the subject child(ren):Case Name:Case Number:Location of Court:Date Filed: (Mo./Day/Yr.)Date Concluded: (Mo./Day/Yr.)Type of Case:20c.002Other court case involving the subject child(ren): which is still pending:Case Name:Case Number:Location of Court:Date Filed: (Mo./Day/Yr.)Date Concluded: (Mo./Day/Yr.)Type of Case: FC-Adm 12/11Page 3 of 4 PagesCUDA AFFIDAVIT OF PLAINTIFFAmerican LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI217IFAMILY COURTFIRST CIRCUITAFFIDAVIT OF PLAINTIFF(FOR UNCONTESTED CIVIL UNION DIVORCE)Page 4 of 4 PagesCASE NUMBERFC-CU No.21.002Plaintiff agrees to the custody arrangement and child support amounts as provided in the proposed civildivorce decree. 22.Child Support:22a.002Plaintiff believes that the information provided in the completed Child Support Guidelines Worksheetis accurate to the best of the Plaintiff220s knowledge and proposed child support is consistent with theChild Support Guidelines Worksheet.22b.002Proposed child support varies from the Child Support Guidelines Worksheet because of theexceptional circumstances: 23.Kids First:23a.002I attended the Kids First Program on(Mo./Day/Yr.). 23b.002I was excused by Judge from attending the Kids First Program.24.002Other:Plaintiff declares that he/she understands that his/her signature under oath before a notary public ishis/her solemn statement that he/she read this Affidavit and