THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PETITION FOR LEGAL SEPARATION 1. Petitioner Name Date of Birth E-mail Address Residence Address Mailing Address (if different) Telephone Number (Home) 2. (Work) Respondent Name Date of Birth E-mail Address Residence Address Mailing Address (if different) Telephone Number (Home) 3. (Work) City and state where parties were married or joined in civil union Date of Marriage or Civil Union 4. Length of time petitioner has been a resident of New Hampshire: _________________________ 5. List minor children born to, or adopted by, the parties either before or during the marriage or civil union: Name Date of Birth Name Date of Birth 6. 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 Service Division of Child Support Services - Legal Unit 129 Pleasant Street Concord, NH 03301 NHJB-2059-FS (12/27/2007) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: PETITION FOR LEGAL SEPARATION 7. To the knowledge of the parties, is either party pregnant? Yes No 8. 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 9. Grounds for legal separation: (Check one or both) Irreconcilable differences have developed that have caused the irremediable breakdown of the marriage or civil union. Other: 10. Are there any pending adoption, juvenile, domestic violence, domestic relations, paternity, legitimation, custody, parental rights and responsibilities, or other proceedings in any court in any state affecting any child(ren) named in this petition or parents of those children? Yes No If yes, specify 11. Requests for court orders: • TEMPORARY. The Petitioner respectfully requests 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 Use of personal property and payment of debt Alimony • Parenting Plan Use of family home Other: FINAL. The Petitioner respectfully requests 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: Attorney for Petitioner Petitioner Signature State of , County of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any NHJB-2059-FS (12/27/2007) Date by Signature of Notarial Officer / Title Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com