IN THE DISTRICT COURT OF _______________________ COUNTY, NEBRASKA (county where Complaint filed) ____________________________, (your full name) Plaintiff, vs. ____________________________, (spouse's full name) ) ) ) ) ) Case No. CI _____________ (case number assigned by Clerk of Court) ) Defendant. (your full name) COMPLAINT FOR DISSOLUTION OF MARRIAGE (WITH CHILD(REN)) ) ) ) I ______________________________________, without assistance of an attorney, ask this Court for a Dissolution of Marriage. In support of my Complaint, I state that the following items are true: 1. I live at ___________________________________________________, (your street address: if confidential under Nebraska or Federal law, enter county and state only and provide an alternative address for mailing of notice) in ___________________________________________________________________, (city, county, and state where you live) 2. My spouse's address is _______________________________________, (spouse's street address) (city, county and state where spouse lives) in __________________________________________________________________. 3. Either my spouse or I have lived in the state of Nebraska for more than one year prior to the filing of this Complaint, with the intention of making this state a permanent home. 4. At the time I filed this action, either my spouse or I was living in ______________________ County, Nebraska. (county where Complaint filed) 5. We were married on ___________________________________, (date of marriage) (city and state of marriage) in _________________________________. Page 1 of 7 Complaint for Dissolution of Marriage (with Child(ren)) DC 6:5(1) Rev. 02/15 Pro Se Committee American LegalNet, Inc. www.FormsWorkFlow.com 6. Neither my spouse nor I am a party to any other pending actions for divorce, separation, or dissolution of marriage in this state or in any other state. 7. allies. 8. 9. My marriage is irretrievably broken. My spouse and I have ______________ child(ren) whose custody or (number of children) My spouse is not a member of the Armed Forces of the United States or its welfare may be affected by this divorce. Their names and years of birth are: _____________________________________ (name of child) _____________ (child's year of birth) _____________________________________ (name of child) _____________ (child's year of birth) _____________________________________ (name of child) _____________ (child's year of birth) ____________________________________ (name of child) _____________ (child's year of birth) 10. ______________________________ fit to have the care, custody, and ("I am," "My spouse is," or "Both my spouse and I are") control of our minor child(ren). 11. The following information is provided because of the requirements of the Uniform Child Custody Jurisdiction and Enforcement Act: (a) For the last five years, the child(ren)'s addresses and the persons they have lived with are: DATES: ADDRESS: NAME and CURRENT ADDRESS OF PERSON(S) WITH WHOM THE CHILD(REN) HAVE LIVED: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______________ ______________ ______________ ______________ ______________ Page 2 of 7 Complaint for Dissolution of Marriage (with Child(ren)) DC 6:5(1) Rev. 02/15 Pro Se Committee ___________________ ___________________ ___________________ ___________________ ___________________ American LegalNet, Inc. www.FormsWorkFlow.com (b) Check the box that applies: [] I have not been a party or a witness in any other proceeding concerning the custody of or parenting time with the child(ren). OR [] I have been a party or a witness in another proceeding concerning the custody of or parenting time with the child(ren), as follows: (name of court) (case number) (date of child custody determination, if any) (c) Check the box that applies: [] I know of no other actions or proceedings that could affect this action. This includes actions or proceedings about domestic violence, protection orders, termination of parental rights, and adoptions. OR [] There is currently a proceeding which could affect this action. (name of court) (case number) (date of child custody determination, if any) Page 3 of 7 Complaint for Dissolution of Marriage (with Child(ren)) DC 6:5(1) Rev. 02/15 Pro Se Committee American LegalNet, Inc. www.FormsWorkFlow.com (d) Check the box that applies: [] I do not know the names and addresses of any persons other than my spouse and myself who have physical custody of the child(ren) or claim to have custody or parenting time rights with the child(ren). OR [] The following is a list of the names and addresses of persons other than my spouse and myself who have physical custody of the child(ren) or claim to have custody or parenting time rights with the child(ren): NAME: _________________________ ________________________ 12. 13. ("I am" or "My spouse is") ADDRESS: _____________________________________ ____________________________________ _________________________ able to provide support for the child(ren). During the course of the marriage, my spouse and I have accumulated certain items of property, which should be fairly divided between us. 14. My spouse and I owe certain marital debts and obligations and the responsibility for payment of these debts and obligations should be fairly divided between us. 15. I wish my former name, _______________________________________, (former or maiden name, including first, middle and last names) to be restored to me. 16. judge. Page 4 of 7 Complaint for Dissolution of Marriage (with Child(ren)) DC 6:5(1) Rev. 02/15 Pro Se Committee I want this dissolution of marriage proceeding heard by a District Court American LegalNet, Inc. www.FormsWorkFlow.com 17. Check the box that applies: [] There are no existing restraining orders, protection orders, or criminal no-contact orders regarding either party. OR [] There are one or more existing restraining orders, protection orders, or criminal no-contact orders regarding one or more of the parties. Details are as follows: (a) Type(s) of order(s): [ ] restraining; [ ] protection; [ ] criminal no-contact. (b) Name of court, case number, and date of order for each order: ________________________________________________ (name of court, case number and date of each order) ________________________________________________ ________________________________________________ 18. 19. c