THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) JOINT PETITION FOR LEGAL SEPARATION 1. Petitioner Name E-mail Address (optional) Date of Birth Residence Address Mailing Address (if different) (Work) Telephone Number (Home) 2. Respondent Name E-mail Address (optional) Date of Birth Residence Address Mailing Address (if different) (Work) Telephone Number (Home) 3. City and state where parties were married or joined in civil union Date of Marriage or Civil Union 4. Length of time parties have been residents of New Hampshire (P) (R) 5. List minor children born to, or adopted by, the parties either before or during the marriage or civil union: Name Date of Birth Current Address If there are minor children born to or adopted by the parties either before or during the marriage or civil union, complete questions 6 – 9. This information is required under RSA 458-A, the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA). It is important that you answer these questions with as much detail and accuracy as possible. Lack of adequate information could significantly delay orders being issued in your case. There are several situations that might result in New Hampshire exercising jurisdiction over child/ren. The continuous presence of the child/ren in New Hampshire for six (6) months is not the only basis for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a temporary basis. NHJB-2060-FS (12/01/2010) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JOINT PETITION FOR LEGAL SEPARATION 6. List the places where the minor child/ren of the parties has/have lived in the last five (5) years and the names of the people they lived with at that time, if you know. Start with where the child lives now and work backward in time. Dates From/To Town/City, State Parent(s)/Caretaker Current Address/Contact Address of Parent/Caretaker Which Child/ren If more space is needed, attach Extra Page (Form NHJB-2656-FPS). I have attached Form NHJB 2656-FPS because additional space was needed. 7. Are there any person(s), not a party to this proceeding, who have physical custody of the child/ren or who claim to have custody, physical custody or parenting time rights? Yes No If yes, list name(s) and address(es) of person(s): 8. Check one of the following: I have not participated in any court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. OR I have participated in court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following: Name of Court State Case No. Date of Court Order 9. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and responsibilities, termination of parental rights, adoption, juvenile, or other proceedings in any court in any state affecting any children named in this petition or parents of those children? Yes No If yes, complete the following: Name of Court NHJB-2060-FS (12/01/2010) State Case No. Page 2 of 4 Type of Court Case American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JOINT PETITION FOR LEGAL SEPARATION 10. Please check one of the following regarding public assistance. No public assistance (TANF) is now being or has within the last 6 months been provided, nor is medical assistance (Medicaid) presently being provided, for any minor child of the parties. The N. H. Department of Health and Human Services is providing or has provided within the last 6 months public assistance (TANF) and/or medical assistance (Medicaid) for a minor child or children of the parties. If you check this box, you must mail copies of this petition and the Personal Data Sheet (NHJB-2077-FS) to DHHS at: New Hampshire Department of Health and Human Services Division of Child Support Services - Legal Unit 129 Pleasant Street Concord, NH 03301 11. To the knowledge of the parties, is either party pregnant? Yes No 12. Do the parties own real estate jointly? Does the petitioner own real estate individually? Does the respondent own real estate individually? Yes Yes Yes No No No 13. The cause for legal separation is: (Check one or both) Irreconcilable differences have developed that have caused the irremediable breakdown of the marriage or civil union. Other: 14. Requests for court orders: A. TEMPORARY. The parties respectfully request that the Court issue temporary orders on any of the following issues. (Check all that apply). A temporary order is in effect until the legal separation is granted. Child support Parenting Plan Use of personal property and payment of debt Alimony Use of family home Other: B. FINAL. The parties respectfully request that the Court grant a legal separation, equitably divide personal property, real estate, debts and obligations of the parties, and issue a final order approving or establishing the following (Check all that apply): A parenting plan which describes the parties’ parental rights and responsibilities relating to minor children; Child support obligations for any minor children; Alimony; Any other relief which may be appropriate; Other: I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child/ren in this case. I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Signature of Petitioner State of , County of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any by Signature of Notarial Officer / Title Signature of Attorney for Petitioner Printed Name, Address and Phone Number of Attorney NHJB-2060-FS (12/01/2010) Bar # Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JOINT PETITION FOR LEGAL SEPARATION I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child/ren in this case. I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Signature of Respondent State of , County of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any by Signature of Notarial Officer / Title Signature of Attorney for Respondent Printed Name, Address and Phone Number of Attorney NHJB-2060-FS (12/01/2010) Bar # Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com