State of New Hampshire CASE NUMBER PERSON A This form must be word processed or typewritten. The following information will be completed by the petitioner as indicated or by one of the joint petitioners and filed with the court prior to the hearing on the merits in accordance with court rules. 1a. Person A’s name – First Middle 1.b. Suffix. 1c. Last name & suffix before 1st marriage or CU Last (Current) (if applicable) 2. Person A’s gender Male Female 3a. Residence – City, town or location (at time of filing) 3b. County 4. Birthplace 5. Date of birth 6. Number of this marriage or CU (State or Foreign Country) (MM/DD/YYYY) Death Number Civil Union Dissolution Divorce/Annulment Number 10a. Person B’s name – First Middle Elementary or secondary Number College (1-4 or 5+) (0-12) 10c. Last name & suffix before 1st marriage or CU 10.b. Suffix Last (Current) 7. Social security number 9. Education: (specify highest grade completed) (do not include current marriage or civil union) (if applicable) 11. Person B’s gender Male Female 12a. Residence – City, town or location (at time of filing) 12b. County 13. Birthplace 14. Date of birth 15. Number of this marriage or CU (State or Foreign Country) (MM/DD/YYYY) 12c. State (Specify first, second, etc.) (do not include current marriage or civil union) Death Number Civil Union Dissolution Divorce/Annulment Number Elementary or secondary Number College (1-4 or 5+) (0-12) 19c. State (City/Town ) 20. Date of this marriage (or foreign country) 19. Place of this marriage or civil union 19b. County 16. Social security number 18. Education: (specify highest grade completed) 17. If previously joined in marriage or civil union, how many ended by: MARRIAGE / CIVIL UNION 3c. State (Specify first, second, etc.) 8. If previously joined in marriage or civil union, how many ended by: PERSON B STATE FILE NUMBER Certificate Of Divorce, Civil Union (CU) Dissolution Legal Separation Or Annulment or CU (MM/DD/YYYY) 21. Date couple last resided in same household (MM/DD/YYYY) ATTORNEY 22a. Number of children born alive or 22b. Number of children under age 18 in adopted during this marriage/civil union this household as of date in Item 21 23a. Name of person completing form: attorney self represented (Street and Number, City/Town, State, Zip Code) 23b. Address attorney self represented 23c. Date (this form was completed) (MM/DD/YYYY) BELOW THIS LINE TO BE COMPLETED BY THE COURT 24b. Cause for filing 24a. Date petition 24c. A decree was entered: There was an: filed with court Irreconcilable differences Uncontested hearing (MM/DD/YYYY) Other (specify) Contested hearing Defaulted hearing DECREE 25b. Date decree becomes final: 26a. Name of hearing official: (first and last name) (MM/DD/YYYY) 27a. Name to be used by Person A after divorce: Same as present (1a & b) Name prior to 1st marriage or CU (1c) Other (specify) 27b. Name to be used by Person B after divorce: Same as present (10a & b) Name prior to 1st marriage or CU (10c) Other (specify) 28. Decision making responsibility for child/children shall be with: Both Parents Person A Person B Other (specify) Not applicable 29a. Number of children under age 18 for whom residential responsibility is with: Both Parents # Person A # Person B # Other (specify) # Not applicable 32a. Signature of court official: I certify that the above is correct to the best of my knowledge. 25a. Type of decree Divorce Legal separation Annulment CU Dissolution 26b. Official capacity: Judge Marital Master 32b. Court name: 30. Residential responsibility was: Uncontested Contested Defaulted Not applicable 31. Petitioner: Person A Person B Joint Other (specify) 32c. Date signed: (MM/DD/YYYY) SOS/DVRA VS 14A Rev 12/2010 American LegalNet, Inc. www.FormsWorkFlow.com