IN THE FAMILY COURT OF ________________ COUNTY, WEST VIRGINIA. In Re: The Marriage / Children of: Civil Action No. ____________ _________________________, and _________________________. Petitioner Respondent __________________ __________________ Social Security Number Social Security Number _________________________ _________________________ _________________________ _________________________ Address Address ________________ ________________ Daytime phone Daytime phone PETITION FOR DIVORCE I , ________________________________, the Petitioner, upon oath, state that the following facts and allegations are true of my personal knowledge; and if I have set forth matters upon information given to me by others, I believe that information to be true. Check the boxes and fill in the blanks for all items that apply to your case. Are you currently a party to a domestic violence proceeding? [ ] Yes [ ] No 1. [ ] Petitioner has been a resident of West Virginia for more than one year prior to filing this divorce case. [ ] Respondent has been a resident of West Virginia for more than one year prior to the filing of this divorce case. [ ] Petitioner and Respondent were married in West Virginia, and at least one of them resides in West Virginia at this time. 2. This action is being brought in _____________________________ County, West Virginia because: [ ] This is the county where the Petitioner and Respondent last lived together as husband and wife. [ ] This is the county where the Respondent now resides. [ ] This is the county where the Petitioner now resides, and the Respondent is not a resident of West Virginia. [ ] Other reasons: (Explain) _______________________________________________________ SCA-FC-101 (12/01) Petition for Divorce Page 1 of 7>>>> 23. Petitioner currently resides in _______________________ County, West Virginia. 4. Respondent currently resides: Check only one of the following three items. [ ] In ______________________________ County, West Virginia. [ ] At an address unknown to the Petitioner. [ ] Out of state, where the last known address was _____________________________________ ________________________________________________. 5. Petitioner and Respondent were married in _______________________County, in the state of _______________________ , on the ____ day of ________________________, _______. 6. Petitioner and Respondent last lived together as husband and wife in _____________________ County, in the state of ___________________________, at the address of ___________________ ________________________________ . Petitioner and Respondent separated on the ____ day of ______________________ , 200___ , and that separation has been continuous and uninterrupted since that date. 7. a. Is either party to this case under the age of eighteen? [ ] Yes [ ] No b. Is either party to this case currently serving on active duty with the military services of the United States? [ ] Yes [ ] No c. Is either party to this case legally incompetent? [ Yes [ ] No ] d. Is either party to this case currently incarcerated? [ ] Yes [ ] No 8. Petitioner and Respondent are the parents of: [ ] No children were born during this marriage, and no children are expected. [ ] The children whose names, dates of birth, and social security numbers are: Name Date Of Birth Social Security No. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ In the rest of this Petition, the children always means the children whose names you just listed. [ ] A child is currently expected, and the estimated date of delivery is ___________________ . SCA-FC-101 (12/01) Petition for Divorce Page 2 of 7>>>> 39. The children currently live with: [ ] Mother [ ] Father [ ] Another person, or persons, whose name(s) and address(es) are: _______________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 10. During the last five years, if any of the children have lived at addresses other than their current address, use the following space to list where they lived, and for how long. If there is not enough room in the following space, use an additional sheet of paper. I have attached ____ additional sheet(s). Childs Name Address Dates of Residence ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 11. Who provides health insurance for the children? [ ] Mother [ ] Father [ ] Medicaid [ ] WV CHIP [ ] Another person, whose name and address are: _____________________________________ _______________________________________________________. [ ] The children DO NOT have health insurance coverage. The West Virginia Childrens Health Insurance Program (WV CHIP) can help parents obtain free or low cost health care for their children. For more information, call 1-877-982- 2447, or ask the Family Court staff about WV CHIP. 12. Answer all of the following questions. a. Has the Petitioner been a party or witness in any other proceeding, in any state, concerning the allocation of custodial responsibility for the children? [ ] Yes [ ] No b. Is the Petitioner aware of any other proceeding, past or present, in any state, concerning allocation of custodial responsibility for the children? [ ] Yes [ ] No c. Is the Petitioner aware of any person other than the parties to this case who has physical custody of or claims any custodial right concerning the children? [ ] Yes [ ] No SCA-FC-101 (12/01) Petition for Divorce Page 3 of 7>>>> 413. Check all of the following items that apply. [ ] The children have resided in West Virginia for at least 6 months immediately preceding the filing of this case, or from birth if less than six mon