STATE OF HAWAI221I FAMILY COURT FIRST CIRCUIT MATRIMONIAL ACTION INFORMATION CASE NUMBER FC-D No. PLAINTIFF PREPARED BY: ~ PLAINTIFF ~ ATTORNEY FOR PLAINTIFF ~ DEFENDANT ~ ATTORNEY FOR DEFENDANT DATE FILED: DEFENDANT NATURE OF CASE: ~ DIVORCE ~ SEPARATION ~ ANNULMENT ~ OTHER ITEM PLAINTIFF DEFENDANT FULL NAME BIRTH OR MAIDEN NAME ADDRESS STREET, APT. NO. CITY, STATE, ZIP CODE CONTACT INFORMATION HOME PHONE NO. CELL PHONE NO. HOME PHONE NO. CELL PHONE NO. E-MAIL ADDRESS E-MAIL ADDRESS SOCIAL SECURITY XXX-XX255XXX-XX255YEAR OF BIRTH PLACE OF BIRTH (State or Country) RACE HIGHEST GRADE COMPLETED HAWAI221I RESIDENT SINCE CIRCUIT RESIDENT SINCE PRIMARY EMPLOYER (Name and Address) JOB TITLE WORK SCHEDULE LENGTH OF SERVICE GROSS MONTHLY INCOME (All Sources) Primary Secondary Welfare Primary Secondary Welfare DATE OF THIS MARRIAGE DATE COUNTY/STATE DATE OF SEPARATION ~ Not Separated DATE COUNTY/STATE In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Court, Family Court office by telephone at 9542558200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. FC Adm 12/26/13 (Continue on back page) MATRIMONIAL ACTION INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com MATRIMONIAL ACTION INFORMATION (Continued) CASE NUMBER FC-D No. FROM MONTH/YEAR TO MONTH/YEAR TERMINATED BY DIVORCE ANNULMENT DEATH STATE Plaintiff222s Prior Marriage(s) Plaintiff222s Prior Civil Union(s) Defendant222s Prior Marriage(s) Defendant222s Prior Civil Union(s) CHILDREN: ALL CHILDREN OF EITHER PARTY FROM YOUNGEST TO OLDEST CHILD222S FULL NAME M/F BIRTHDATE LEGAL PARENT PRESENT CUSTODY (PLAINTIFF, DEFENDANT, OR OTHER) SCHOOL AND GRADE INFORMATION REQUIRED FOR CUSTODY OF PARTIES222 CHILD(REN) TOGETHER CHILD(REN)222S PRESENT ADDRESS: PLACE(S) WHERE AND PERSON(S) WITH WHOM THE CHILD(REN) HAVE LIVED WITHIN THE LAST FIVE YEARS AND DATES ADDRESS CARETAKERS FROM MONTH/YEAR TO MONTH/YEAR GPLAINTIFF GIS GIS NOT PREGNANT. EXPECTED DELIVERY DATE: GDEFENDANT GIS GIS NOT PREGNANT. EXPECTED DELIVERY DATE: THE UNDERSIGNED SOLEMNLY AND SINCERELY DECLARES, UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE,INFORMATION, AND BELIEF. DATE SIGNATURE FC Adm 12/26/13 Page 2 MATRIMONIAL ACTION INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com