THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PERSONAL DATA SHEET 1. Name of person(s) completing this form (Check if applicable) Because I believe that my safety, or the safety of my children is at risk, I request that the information contained in this Personal Data Sheet not be disclosed to the other party. The reasons are: 2. Type of case filed today: Petition for Divorce Petition for Legal Separation Joint Petition for Legal Separation Joint Petition for Divorce Domestic Violence Petition Petition for Civil Union Dissolution Parenting Petition Joint Petition for Civil Union Dissolution Paternity/Legitimation Petition to Change Court Order/Modification Other: Date of Birth 3. Name of Petitioner State of Birth Social Security Number Residence Address Mailing Address (if different) Phone number (home) (work) E-mail Address Employer’s Name and Address Date of Birth 4. Name of Respondent State of Birth Social Security Number Residence Address Mailing Address (if different) Phone number (home) (work) E-mail Address Employer’s Name and Address 5. Child(ren)’s Full Name(s) Date of Birth Social Security # Date Signature Date Signature (if joint petition) NHJB-2077-FS (12/27/2007) Page 1 of 1 State of Birth American LegalNet, Inc. www.FormsWorkflow.com