3. Petitioner's present residence address (including street, city, state, zip code, and county):
    _____________________________________________________________________

4. Respondent's present residence address including street, city, state and zip code):
    ____________________________________________________________________

5. Petitioner's home telephone no.:___________________ work no.:__________________

6. Respondent's home no.: _____________________ work no.:_____________________

7. Date of Marriage:__________________________ Place of marriage (city and state,
    country, etc.):__________________________________________________________

If living apart, date of separation:_____________________________________________

8. Where did you last live together as husband and wife (city and state, country, etc.)?
    _____________________________________________________________________

9. List the full name(s), birthdates, sex and Social Security Number of the minor/dependent child/children common to both parties (including adopted child/children as well as children born during the marriage where the Husband is not the father including the name of the father for the child/children when the Husband is not the father):

Full Name                                     Birthdate                         Sex                               SS#                     Place of Birth (City and State)

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

10. Is the Wife pregnant? YES or NO (Circle One) If YES, what is the due date: _________________________

11. (a) List the names, addresses and dates (from and to) for the children and the name and relationship of the persons with whom the children lived at each address for the past five years:

Child's Name                                    Address                       Dates for Residence                          Relation Lived With
                                                                                                   (From / To)                                      (including parents)

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

(b) Have you participated in any other custody proceeding regarding the children? If so, give the name of the child, the type of proceeding, the location of the court (state and county), and the date of the order or judgment (if any):_____________________________________________

______________________________________________________________________

______________________________________________________________________

(c) Does any other person who is not a party to this action have physical custody or claim to have visitation rights? If so, give the name of the child involved, the name of the person, whether the person has custody or claims visitation rights.

______________________________________________________________________

______________________________________________________________________

(d) Are the child(ren) subject to any existing child support order(s)?  YES or NO (circle one).  If yes, please state:    name of child, type of proceeding, court and address, date of order(s) and amount of support paid and by whom:_________________________________________

______________________________________________________________________

______________________________________________________________________

12. You will need a residency witness (someone that knows that you have been a Florida resident for 6 months prior to filing this action). The witness must sign an affidavit that we will provide. What is the full name, complete address and phone number of your residency witness? _____________________________________________________________________________________

_____________________________________________________________________________________

NOTE:   If you are not sure who you will get to sign the form you may request a blank form here.  _______________________________

13. (a)  Is the Respondent over the age of 18? YES or NO (Circle One)

      (b)  Is the Respondent an active-duty member of the United States Uniformed Military Services? YES or NO (Circle One)

14. Is the Petitioner an active-duty member of the United States Uniformed Military Services? YES or NO (Circle One)

15. Is the Wife requesting her maiden or a former married name be restored? YES or NO (Circle One) If so, please state the full name (no initials) by which the Wife wishes to be known:____________
________________________________________________

16. Is the marriage irretrievably broken and cannot be reconciled? YES / NO (Circle One) If no, seek the advice of a marriage counselor before proceeding.

17. If either party's I.D. (Florida I.D. Card, driver's license; military I.D.) is listed under a different name than what is set out in either questions 1 or 2, please indicate the name as shown on the I.D. _________________________________________________ and provide an enlarged readable copy of the I.D.

18. Have you and your spouse already signed a written Marital Settlement Agreement? YES or NO (Circle One)
     A. If YES, provide the date it was entered into and provide the original
          so that it can be filed with your petition and made a part of
          your Final Judgment (divorce decree).
          Date Agreement was signed:___________________
     B. If NO, please fill out Questions 19 through 30.

     NOTE: The information you provide below will be inserted into a generic marital settlement agreement form which contains a lot of "boiler plate" legal language. A marital settlement agreement is one of the most important documents you will ever sign. In it, you and your spouse will resolve issues regarding the minor children, set out how the assets and liabilities will be divided and also resolve other issues to your mutual satisfaction. If you do not understand the finished document and how it will impact your life, then you should have it reviewed and explained to you by a lawyer competent in family law. It is solely the responsibility of the parties to independently determine that this document is accurate, complete and appropriate before it is executed and filed with the court.  Clearly describe the issues of your agreement in such a manner whereas a third party of reasonable intelligence can understand your intentions.  It is not necessary to write in "legalese."

19. The minor child/children will reside with which parent? FATHER or MOTHER (Circle One), or other arrangement (explain):

_____________________________________________________________________

_____________________________________________________________________

20. Click here to review the portion of the Shared Parenting Plan for Okaloosa County regarding the timesharing plan for the minor child(ren). This is the court-approved plan for Okaloosa County effective October 1, 2008 (the date the new laws became effective).  Include any deviations from this Plan which the parties wish to be included in an Addendum.   If more space is needed, attach details on a separate sheet of paper .______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

21. Is child support to be paid at this time or is the Court to reserve the right to award support at a later time. In order for the court to approve that child support be reserved there must be a good reason given.  Parents cannot waive child support. CHILD SUPPORT or RESERVED (Circle One). For child support to be paid, state amount $____________ per ______________ (i.e. month; week, etc.) When due (1st; 15th; ½ on 1st and ½ 15th of the month, etc.): __________________________________ When do payments begin___________________
Set forth reason if child support is to be reserved:____________________________________
_________________________________________________________________________

Click here to view section 61.30, Florida Statutes, Florida's Child Support Guidelines.

22. Is the child support to be paid directly to the wife/husband or is it to be paid through the Clerk of the Circuit Court, Alimony and Child Support Division? ______________________________

If paid through the Court, a handling charge of 4% (minimum of $1.25 and maximum of $5.25) will be charged per payment.

     IF CHILD SUPPORT IS TO BE PAID THROUGH THE COURT please answer the following otherwise skip to question No. 23:
(a) Who will pay the child support: Husband/Wife (circle one)
(b) Provide the following information regarding the person paying support:
     (1) Date of Birth:___________________________;
     (2) Social Security No. ______________________________;
     (3) Place and Address of Employment_____________________
           ________________________________________________;
     (4) Other Sources of Income:______________________________
            ___________________________________________________
(c) Provide the following information regarding the person receiving support:
     (1) Date of Birth:___________________________;
     (2) Social Security No.________________________

23. Who is to provide hospitalization, medical and health insurance coverage for the minor child/children? HUSBAND or WIFE (circle one) Are any medical, dental, optical or orthodontic expenses which are not covered, and any excesses in coverage to be divided equally between the parties or are they to be paid by only one party? Equally_______ One Party ________ Who is the one Party: HUSBAND or WIFE (Circle One).  Set forth any special details:______________
_______________________________________________________________________

24. If either party owns life insurance on their life that is to remain in effect for the benefit of the minor child/children while they are minors, state which party: HUSBAND or WIFE  or BOTH (circle one). State other details regarding life insurance: _____________________________

_______________________________________________________________________

_______________________________________________________________________

25. How are the MARITAL ASSETS to be divided. (The property you and your spouse acquired during the marriage.)

     A. Check here _______, if all marital assets have already been equitably divided between the parties to their mutual satisfaction and each party is in possession and control of the particular marital assets they are to receive and TITLES for the property (such as jointly titled automobiles, real estate, businesses, timeshares, boats, planes, motorcycles, motorhomes, etc.) have already been changed into the party's name alone.  No change is needed to a title if the word "or" is between the names on the title instead of "and".  If that is the case, check "B" below and list the property and who is to receive it in "C" below.

                                                                       OR

     B. Check here _______, if some marital assets have already been equitably divided between the parties to their mutual satisfaction but there are other jointly titled assets or other property to be divided. Specifically list the items of property that is not yet divided and who is to receive it below in "C" (such as jointly titled automobiles, real estate, businesses, timeshares, boats, planes, motorcycles, motorhomes etc.).

                                                                     OR

     C. State who gets specific property; i.e., marital residence, automobiles, real property, etc.--In the case of a motor vehicle or mobile home state Cert. of Title #, VIN #, make, year, etc. (this information is on your tag receipt). In the case of the marital home or other real property--state if one party is to have use and possession with both parties to remain joint owners or if one party is to have sole ownership and whether the other party is to sign a quit-claim deed, etc. Use a separate sheet if needed. Provide a copy of the "legal description" of the real estate so it can be inserted in your Marital Settlement Agreement. Be specific and descriptive:

                  Asset Description                                            Who is to own it

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

26. How are the MARITAL LIABILITIES to be divided. (Debts that you and your spouse have acquired during the marriage.)

     A. Check here _________, if all marital liabilities have already been equitably divided between the parties to their mutual satisfaction and each party is to pay debts that are in their name alone.
                                                                                OR

     B. Check here ________, if some of the marital liabilities have already been equitably divided between the parties to their mutual satisfaction and each party is to pay debts that are in their name alone but there are other liabilities still to be divided. Specifically list the liabilities still to be divided in "C" (i.e., such as who pays a joint debt or a debt in the other spouse's name).

                                                                                  OR

     C. List the marital liabilities that have not been divided between the parties state who is to pay the debt; i.e., marital residence, automobiles, real property, credit cards, etc.) Be specific and descriptive:

           Creditor Name/Description                                      Who is to pay debt

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

27. Is alimony to be waived? YES or NO (Circle One)
     If YES, please skip to question No. 28
     If NO, please answer the following:
     a. Who is to receive the alimony: HUSBAND or WIFE (Circle one)
     b. What is the amount (per month/week/etc.) $______________ per _________
     c. How is it to be paid (i.e., weekly [giving day due such as Mondays], monthly [giving due date such as 1st or 15th or
        one-half on 1st & one-half on 15th):
         _____________________________________________________________
     d. When do payments begin:__________________________________________
     e. When does alimony end (i.e., for a set length of time; when the Wife/Husband remarries, dies, cohabits with another man/woman, etc.).
         Please give details:___________________________________________________
          ________________________________________________________________
          ________________________________________________________________
          ________________________________________________________________
          ________________________________________________________________
     f. Is it to be paid directly to the wife/husband or paid through the Clerk of the Circuit Court, Alimony and Child Support Division __________________________

If paid through the court, a handling charge of 4% (up to $5.25) will be charged per payment.

IF ALIMONY IS TO BE PAID THROUGH THE COURT please answer the following. If not skip to question No. 28:

(a) Provide the following information regarding the person paying support:
     (1) Date of Birth:_________________________;
     (2) Social Security No. ___________________________;
     (3) Place and Address of Employment_____________________
           ______________________________________________;
     (4) Other Sources of Income:___________________________
            _____________________________________________
            ________________________________________________
(b) Provide the following information regarding the person receiving support:
     (1) Date of Birth:____________________________;
     (2) Social Security No._______________________

28. Are the parties waiving their right to the other party's retirement, if any? YES / NO / NA (Circle one) If NO, please give details including amount (or percentage), when payments begin, date payments due (such as 1st; 15th), whether paid directly to spouse or by allotment, etc ____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

29. Who will claim the child\children for income tax purposes in the future? HUSBAND or WIFE (Circle One) Or if to be divided  or alternated,state details: ________________________

____________________________________________________________________

____________________________________________________________________

30. State any other agreement between the parties that should be included in the Marital Settlement Agreement. Agreements which are not included in the Marital Settlement Agreement may not be enforceable, so get it in writing. Use a separate sheet of paper if needed (write "none" if there are no other issues remaining to be resolved):

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

I/We, the undersigned, have provided the foregoing information which is complete and to be inserted into my/our forms for an uncontested Dissolution of Marriage.  Only one signature is required below in the event a spouse is out of the area and unavailable to sign this form.

Please provide the name and e-mail address to contact in the event clarification is required: _______________________________________________________________

Dated:______________________

____________________________________
Customer's Signature

____________________________________
Customer's Signature

Credit Card Information (If Paying by Credit Card):
(Print clearly or type)