DRjpa3-16 FORM 22 Must type or print neatly in ink Common Pleas Court of Montgomery County, Ohio A2 B2 C2 D2 DOMESTIC RELATIONS DIVISION Divorce and Dissolution Questionnaire Case No. ________________________________________ Legal Separation Dissolution Divorce Annulment JUDGE________________________________________ Type of Action: Plaintiff / Petitioner _________________________________________________ Last First Middle Defendant / Petitioner NAME _______________________________________________ Last First Middle ___________________________________________ MAIDEN NAME OR ALIAS _________________________________________ ADDRESS ADDRESS PHONE _______________________________________________ Street# Street Name Apt.# _________________________________________________ Street# Street Name Apt.# ________________________________________________ City State Zip County _______________________________________________ City State Zip County _________________________________________________ Area Code Phone Number _______________________________________________ Area Code Phone Number SSN:_____ -_____ -________ DOB ______/_______/________ AGE______ ACTIVE DUTY MILITARY? ____ YES, STATIONED:___________________ CURRENTLY PREGNANT? ____ YES, DUE DATE: _____/_____/______ SSN:_____ -_____ -________ DOB ______/_______/________ AGE______ ACTIVE DUTY MILITARY? ____ YES, STATIONED:__________________ CURRENTLY PREGNANT? ____ YES, DUE DATE: _____/_____/______ _____________________________________________ ___________________________________________ Area Code Phone Number ATTORNEY NAME _____________________________________________ ATTORNEY PHONE ___________________________________________ Area Code Phone Number ___________________________________________ COURT USE ONLY ATTORNEY ADDRESS ____________________________________________ DATE HEARD: ______________________ BY:_____________________________ Date Complaint / Petition Filed __________________________________ Service: Waived _____________________ PERS ______________________ Reg. Mail _________________ Cert. Mail____________________ Answer: ___________________ Ans./Counterclaim___________________ AWARDED TO: GROUNDS: Plaintiff /Petitioner Defendant / Petitioner ____EC ____Disso _____ Incompat ____GN ____ Separate & Apart ____Other DECREE to be filed on/before _______________________________________ Pl.Notice Date__________________ Def. Notice Date _________________ By Attorney________________________________________ QDRO / DOPO by _______________________________________ ======================================================= RESIDENTIAL PARENT: Plaintiff/Petitioner Defendant/Petitioner Shared Parenting N/A Pretrial Date _____________ Trial Date _____________ _______________ _______________ _______________ _______________ Date Decree Filed _____________________________________________ Date Case Dismissed __________________________________________ CROSS REFERENCES____________________________________________ (Bankruptcy, DV) _____________________________________________ PED: Pet/PL. ___________________ Pet/DEF. ____________________ Name Restoration: ____________________________________________ ==================================================== SETS #:_________________________________________ Retain Support Jurisdiction Amount Amount & Duration American LegalNet, Inc. www.FormsWorkFlow.com ======================================================== PARENTING TIME: Standard Per Decree Standard after PAD None until Further Order ======================================================= SUPPORT AMOUNT(S): $________________________ per MONTH per child x _____child(ren) Healthcare _____ Pet/PL. ____ Pet/DEF. $________________________ per MONTH per child x _____child(ren) (No healthcare at reasonable cost) $ __________________ Cash Medical $___________________ Spousal Support/month for____________________ SOCIAL HISTORY Marriage: Date ___________________________ City __________________________________________________ State _____________________ Cohabitating at Present: ____ Yes ____ No, Date of Separation _________________ Who first left home? _________________________ Plaintiff / Petitioner Ohio ______________ Montgomery Co. ___________ City______________________________ State ________ Time of Residence In Birthplace EDUCATION (indicate years completed) Elementary __________ High School _____________ College ______________ Grad School _____________ Other (Specify)__________________________________ Degrees OCCUPATION _________ Yes _________ Yes _________ No _________ No Retired? Currently Working? Employer Position Working Hours Payroll Address (City, State, Zip) Work Phone Number Defendant / Petitioner Ohio ______________ Montgomery Co. ___________ City______________________________ State ________ Elementary __________ High School _____________ College ______________ Grad School _____________ Other (Specify)__________________________________ _________ Yes _________ Yes _________ No _________ No __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ $_____________ from Employer _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ from Employer $_____________ _________ No _________ No from Pension GROSS Earnings PER YEAR $_____________ PUBLIC ASSISTANCE Receive Public Assistance? Application Pending? $____________ from Pension _________ Yes _________ Yes _________ Yes _________ Yes _________ No _________ No PHYSICAL DESCRIPTION Height __________________ Weight _________________ Height __________________ Weight _________________ Hair Color ______________ Eye Color_______________ RACE ____ White ____ Black ____ Asian Other __________________ ____ White ____ Black ____ Asian Other __________________ =================================================================================================== Children of Present Marriage Name 1 2 3 4 5 6 7 8 9 10 D.O.B. Age Sex SS# School (Name) Grade Living With Hair Color ______________ Eye Color_______________ American LegalNet, Inc. www.Forms