CASE NUMBER STATE OF HAWAI‘I MATRIMONIAL ACTION INFORMATION FAMILY COURT ________ CIRCUIT PLAINTIFF FC-D NO. PREPARED: PLAINTIFF DEFENDANT ATTORNEY FOR PLAINTIFF ATTORNEY FOR DEFENDANT DEFENDANT NATURE OF CASE DIVORCE SEPARATION ANNULMENT ITEM DATE FILED OTHER WIFE HUSBAND FULL NAME BIRTH OR MAIDEN NAME ADDRESS STREET, APT. NO. TOWN, STATE, ZIP COUNTY HOME WORK HOME WORK PHONE SOCIAL SECURITY NUMBER DATE OF BIRTH PLACE OF BIRTH (State or Country) RACE HIGHEST GRADE COMPLETED HAWAII RESIDENT SINCE CIRCUIT RESIDENT SINCE PRIMARY EMPLOYER (Name and Address) JOB TITLE WORK SCHEDULE LENGTH OF SERVICE Primary Secondary Welfare Primary Secondary Welfare GROSS MONTHLY INCOME (All Sources) DATE OF THIS MARRIAGE DATE OF SEPARATION NOT SEPARATED Form No. 073105 R12/97 DATE COUNTY / STATE DATE COUNTY / STATE (Continue on back page) American LegalNet, Inc. www.FormsWorkflow.com MATRIMONIAL ACTION INFORMATION 1F-P-082 CASE NUMBER MATRIMONIAL ACTION INFORMATION (Continued) FC-D NO. FROM TO MONTH/YEAR MONTH/YEAR TERMINATED BY DIVORCE ANNULMENT STATE DEATH WIFE’S PRIOR MARRIAGES HUSBAND’S PRIOR MARRIAGES CHILDREN: CHILD’S FULL NAME ALL CHILDREN OF EITHER PARTY FROM YOUNGEST TO OLDEST M/F BIRTHDATE LEGAL PRESENT PARENT CUSTODY (HUSBAND, WIFE OR OTHER) SCHOOL AND GRADE INFORMATION REQUIRED FOR CUSTODY CHILDREN’S PRESENT ADDRESS: PLACES WHERE AND PERSONS WITH WHOM THE CHILDREN HAVE LIVED WITHIN THE LAST FIVE YEARS AND DATES ADDRESS WIFE IS CARETAKERS FROM MONTH/YEAR TO MONTH/YEAR IS 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 American LegalNet, Inc. www.FormsWorkflow.com