IN THE COURT OF COMMON PLEAS, GREENE COUNTY, OHIO DOMESTIC RELATIONS DIVISION , CASE NO. PLAINTIFF/PETITIONER 1 JUDGE HURLEY vs. , DIVORCE/DISSOLUTION DEFENDANT/PETITIONER 2 QUESTIONNAIRE Type of Action: Divorce Dissolution Legal Separation Annulment 1st Language: Is interpreter required? Yes No Hearing Impaired? Yes No Is interpreter required? Yes No Date of Marriage: Date of Separation: Place of Marriage: Parties Still Reside Together? Yes No CHILDREN FROM THIS MARRIAGE Name DOB Age School Grade Resides With REAL ESTATE Owned by Plaintiff/Petitioner 1 Only: Owned by Defendant/Petitioner 2 Only: Joint Holdings: American LegalNet, Inc. www.FormsWorkFlow.com PLAINTIFF/PETITIONER 1 Address: Phone: Race: Gender: Female MaleOther Height: Weight: Hair Color: Eye Color: DOB: Currently Pregnant? Yes No If yes, due date: Birthplace: Length of Residence in OH: Length of Residence in Greene Co: EDUCATION Name of School Years Attended Degree Obtained Type of Degree Yes No Yes No Yes No EMPLOYMENT Employer: Job Title: Active Duty: Yes No Retired: Yes No Annual Income: $ PUBLIC ASSISTANCE Currently Receiving Public Assistance? Yes No If yes, assistance type: Cash Grant Medical Application Pending? Yes No PRIOR DIVORCES/DISSOLUTIONS Date Case # Place CHILDREN FROM PRIOR MARRIAGES/RELATIONSHIPS Name Age Reside With You? Support Paid? Support Received? Yes NoYes NoYes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com EDUCATION Name of School Years Attended Degree Obtained Type of Degree Yes No Yes No Yes No EMPLOYMENT Employer: Job Title: Active Duty: Yes No Retired: Yes No Annual Income: $ PUBLIC ASSISTANCE Currently Receiving Public Assistance? Yes No If yes, assistance type: Cash Grant Medical Application Pending? Yes No PRIOR DIVORCES/DISSOLUTIONS Date Case # Place CHILDREN FROM PRIOR MARRIAGES/RELATIONSHIPS Name Age Reside With You? Support Paid? Support Received? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Address: Phone: Race: Gender: Female MaleOther Height: Weight: Hair Color: Eye Color: DOB: Currently Pregnant? Yes No If yes, due date: Birthplace: Length of Residence in OH: Length of Residence in Greene Co: Page 3 of 3 DEFENDANT/PETITIONER 2 American LegalNet, Inc. www.FormsWorkFlow.com