Free Petition for Civil Union Dissolution - Nebraska

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

PETITION FOR CIVIL UNION DISSOLUTION
1. Petitioner Name Date of Birth Residence Address Mailing Address (if different) Telephone Number (Home) 2. Respondent Name Date of Birth Residence Address Mailing Address (if different) Telephone Number (Home) 3. City and State of Civil Union Date of Civil Union 4. 5. Length of time petitioner has been a resident of New Hampshire: List minor children born to, or adopted by, the parties either before or during the civil union: Name Date of Birth Name Date of Birth (Work) E-mail Address (optional) (Work) E-mail Address (optional)

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 Services Division of Child Support Services - Legal Unit 129 Pleasant Street Concord, NH 03301
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NHJB-2449-FS (04/09/2009)

Case Name: Case Number: PETITION FOR CIVIL UNION DISSOLUTION

7. 8.

To the knowledge of the parties, is either party pregnant? Do the parties own real estate jointly? Does the petitioner own real estate individually? Does the respondent own real estate individually? The cause for dissolution is: (Check one or both)

Yes Yes Yes Yes

No No No No

9.

Irreconcilable differences have developed that have caused the irremediable breakdown of the 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: A. 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 dissolution is granted. Child support Alimony Parenting Plan Use of family home Use of personal property and payment of debt Other:

B. FINAL. The Petitioner respectfully requests that the Court grant a civil union dissolution, 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 _ Printed Name, Address and Phone Number of Attorney

Petitioner Signature Bar #

Date

State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any

, County of by
Signature of Notarial Officer / Title

NHJB-2449-FS (04/09/2009)

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