(B) SELF-HELP FORM #1A PETITION FOR DISSOLUTION OF ... › uploads › cms › 20110621 ›...

Revised 7/18/2007

1

NO. (A)____________________ JEFFERSON CIRCUIT COURT

FAMILY DIVISION _________

(B)__________________________ PETITIONER

(print name of Petitioner)

SELF-HELP FORM #1A

v. PETITION FOR DISSOLUTION OF MARRIAGE

(Without Children Under 18)

(C)__________________________ RESPONDENT

(print name of Respondent)

(D) Domestic Violence Order #___________________

* * * * * * * * *

1. The parties are husband and wife having been lawfully married on ____________

_______________________ in ____________________ County, ________________________, (Date of Marriage) (County) (State)

where the marriage is registered.

2. The Petitioner is ____________________ years of age; he/she presently resides at (Petitioner’s Age)

______________________________, _________________, _____________, _________ (Petitioner’s Street Address) (Petitioner’s City) (Petitioner’s State) (Petitioner’s Zip Code)

and has has not resided in this state continuously for a period of more than 180 days prior to the

filing of this petition.

3. The Respondent is __________________ years of age; he/she presently resides at (Respondent’s Age)

______________________________, _________________, _____________, ______________ (Respondent’s Street Address) (Respondent’s City) (Respondent’s State) (Respondent’s Zip Code)

and has has not resided in this state continuously for a period of more than 180 days prior to the

filing of this petition.

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2

4. The parties are separated, having been separated since ________________________

(E) (Date of Separation)

and having remained separated since that time.

5. The parties have no children together under the age of 18 and, therefore, there are no

issues concerning any children in this divorce proceeding.

6. The Petitioner is not pregnant.

OR

To the best of my knowledge the Respondent is not pregnant.

7. The marriage of the parties is irretrievably broken.

8. Marital Property and Debts:

The parties have no marital property or debts.

OR

The parties have already divided the marital property and debts.

OR

There is marital property and/or debt and there is no agreement as to the division of

the property and/or debt.

ACCORDINGLY, the Petitioner, ________________________, demands as follows: (Petitioner’s Name)

(H)A. Dissolution of the marriage;

B. Maintenance;

That neither party pay maintenance to the other.

OR

The Respondent pay maintenance to the Petitioner.

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OR

The Petitioner pay maintenance to the Respondent.

C. The equitable division of marital property and/or debt, if any, and the restoration of

non-marital property to the appropriate party.

D. Any and all other relief to which Petitioner may appear entitled.

I, ________________________________, have read, or had read to me, the above statements (Petitioner’s Name)

contained in the Petition for Dissolution of Marriage and verify that the statements are true and

accurate to the best of my knowledge and belief.

Petitioner’s Signature

**MUST BE SIGNED IN THE PRESENCE OF A NOTARY OR CIRCUIT CLERK**

COMMONWEALTH OF KENTUCKY )

)

COUNTY OF JEFFERSON )

Subscribed and sworn to before me by the above-named Petitioner on this ______ day of

___________________, 200____.

My commission expires: _______________________.

NOTARY PUBLIC

STATE AT LARGE, KENTUCKY or

CIRCUIT CLERK

Revised 7/18/2007

NO. (A) ____________________ JEFFERSON CIRCUIT COURT


(B)__________________________ PETITIONER


SELF HELP FORM #2

v. ENTRY OF APPEARANCE AND WAIVER

(C)__________________________ RESPONDENT


* * * * * * * * *

The Respondent comes without counsel and states:

I have read the Petition, have understood it, and do not contest it. I waive service of

summons, enter my appearance, and submit to the jurisdiction of the Court. I understand that, if my

spouse has an attorney, that attorney does not represent me, and that I may hire my own attorney but

choose not to do so. I waive service of any notice of hearing, taking of deposition, motion to submit

for judgment, or entry of judgment. I waive any right of appeal.

(D)

(signature of Respondent)


)


Subscribed and sworn to before me by the above-named Respondent on this ________ day of

____________________, 200____.

My commission expires: _________________________.

Notary Public

State at Large, Kentucky or

Deputy Clerk

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1



(B) __________________________ PETITIONER


SELF-HELP FORM #2A

v. MANDATORY CASE DISCLOSURE

(Without Children Under 18)

(C) __________________________ RESPONDENT


* * * * * * * * *

I. (D) INFORMATION ON PETITIONER:

Name:

Address:

Telephone Number:

Age: Date of Birth:

Date and Place of Marriage to Respondent:

Check One: EMPLOYED UNEMPLOYED DISABLED RETIRED

Name and Address of Employer: _____________________________________________

________________________________________________________________________

Petitioner’s average income: $______________ weekly monthly annually

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II. (E) INFORMATION ON RESPONDENT:

Name:

Address:

Telephone Number:

Age: Date of Birth:

Check One: EMPLOYED UNEMPLOYED DISABLED RETIRED

Name and Address of Employer: _____________________________________________

_________________________________________________________________________

Respondent’s average income: $______________ weekly monthly annually

III. (F)NON-MARITAL PROPERTY:

Petitioner’s Non-Marital Property: (attach additional sheets if necessary)

List all property acquired by the Petitioner before the marriage or by gift or inheritance

during the marriage

Respondent’s Non-Marital Property: (attach additional sheets if necessary)

List all property acquired by the Respondent before the marriage or by gift or inheritance

during the marriage

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IV. (G) MARITAL PROPERTY:

(H) Personal Property - Have you and your spouse agreed on a division of your household

goods and furnishings?

Yes No

(I) If no, list personal property, such as furniture, household items, yard equipment, guns,

tools, knife collection, etc.

Description

Value

Debt

(J) Do you or your spouse have any cars, trucks, boats, 4-wheelers?

Yes No

If yes, please describe: Description

Name(s) on Title:

Value

Debt

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(K) Do you and your spouse have any bank accounts:

Yes No

If so, please list here:

Name on Account

Name of Bank

Balance

Checking

Savings

Checking

Savings

Checking

Savings

V. (L) REAL PROPERTY:

Do you and your spouse have any real estate?

Yes No

If so, Please list here:

Address

Name on Deed

Value

Debt

VI. (M) RETIREMENT:

Do either you or your spouse have a retirement plan through your employer, such as a

pension, profit sharing or 401k or a private plan such as an IRA?

Yes — Complete this Section

No — Skip to Section VIII

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Petitioner’s Retirement Plans:

a) ________________________________ Name of Plan/Account

Type of Plan (complete one)

IRA — ________________________ Balance

401k — ________________________; ________________________ Employer Name Balance

Pension — ________________________ Employer Name

b) ________________________________ Name of Plan/Account


IRA — ________________________ Balance



For more plans or accounts, attach additional sheets.

Respondent’s Retirement Plans:

c) ________________________________ Name of Plan/Account


IRA — ________________________ Balance



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d) ________________________________ Name of Plan/Account


IRA — ________________________ Balance



VII. (N) OTHER PROPERTY (e.g., Stocks or Bonds):

Do you or your spouse have any other property of value that you have not listed?

Yes No

If so, list that property below: Description of Property

Value

VIII. (O) DEBT (not otherwise listed)

Do you or your spouse have any other debt not previously listed?

If so please describe below:

Creditor Name(s) on Account Balance Owed Payment

_________________ ______________________ _____________ ____________ Delinquent

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_________________ ______________________ _____________ ____________ Delinquent

_________________ ______________________ _____________ ____________ Delinquent

_________________ ______________________ _____________ ____________ Delinquent

_________________ ______________________ _____________ ____________ Delinquent

_________________ ______________________ _____________ ____________ Delinquent

_________________ ______________________ _____________ ____________ Delinquent

(P) Signature of person filing

Mandatory Case Disclosure

(P) Printed name of person filing

Mandatory Case Disclosure

(Q) Address

(R)Telephone Number

**MUST BE SIGNED IN THE PRESENCE OF A NOTARY OR CIRCUIT CLERK**

(S) COMMONWEALTH OF KENTUCKY )

)


Subscribed and sworn to before me by the above-named Petitioner/Respondent on this

______ day of ___________________, 200____.


NOTARY PUBLIC

STATE AT LARGE, KENTUCKY or

CIRCUIT CLERK

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8

CERTIFICATION

I hereby certify that, to the best of my knowledge and belief, the name, complete address and

telephone number of the other person involved in this action as listed below is:

__________________________

(T) Name of other party

__________________________

Street number and name

__________________________

City, State, ZIP

__________________________

Telephone number

I have filed this Mandatory Case Disclosure with the Clerk of the Jefferson Circuit Court,

Family Division, and have mailed a copy of the Mandatory Case Disclosure and supporting

documentation to the other party involved in this action.

(U) Signature

Date

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1



(B)__________________________ PETITIONER

(Print name of Petitioner)

SELF-HELP FORM #2C

v. RESPONDENT’S MANDATORY CASE

DISCLOSURE ACKNOWLEDGMENT

(C)__________________________ RESPONDENT

(Print name of Respondent)

I, ___________________,hereby acknowledge that I have received the Name (Respondent)

Petitioner’s Mandatory Case Disclosure and acknowledge that it is a true statement of our

assets and liabilities.

______________________________

SIGNATURE OF RESPONDENT

**MUST BE SIGNED IN THE PRESENCE OF A NOTARY**


)


Subscribed and sworn to before me by the above-named Respondent on this ______ day of

___________________, 200____.


NOTARY PUBLIC

STATE AT LARGE, KENTUCKY

Revised 7/18/2007

1



(B)__________________________ PETITIONER


SELF-HELP FORM #3A

v. MARITAL SETTLEMENT AGREEMENT

(Without Children under 18)

(C)__________________________ RESPONDENT


* * * * * * * * *

The parties agree to the following:

I. The parties are husband and wife. Irreconcilable differences have arisen between

them, resulting in the filing of a petition for dissolution of their marriage.

II. The parties are separated and living apart, and have no expectation of resuming a

marital relationship.

III. The parties wish to settle the issues of maintenance, division of property and

assignment of debts.

IV. (D)NON-MARITAL PROPERTY

There is no non-marital property that has not already been restored to the party to whom it

belongs.

OR

The following non-marital property will be restored to the Petitioner:

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The following non-marital property will be restored to the Respondent:

V. (E) MARITAL PROPERTY

A. (F) Real Estate

The parties own no marital real estate.

OR

The parties have agreed to sell the real estate located at _______________

__________________________________________, and the parties will split the net proceeds of (address, including city and state)

the sale with Petitioner receiving _____% and Respondent receiving _____%.

OR

The Petitioner Respondent is awarded the real estate located at ______

____________________________________________. The party who is keeping the property will (address, including city and state)

pay all obligations on the real estate, including the taxes owed and the mortgage. The party who is

keeping the property shall refinance the debts associated with the property within____ days. The

party who is keeping the property shall pay the other party nothing or $____________ within (amount of money)

_______days of signing this Agreement to pay for the other party’s share of the equity in the

property.

**The party who is not keeping the real estate shall sign a Quitclaim Deed on the property at the time

he/she receives payment for his/her share of the property or if no payment is due, within 30 days of

the date of the Agreement

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B. (G)Vehicles

The Petitioner is awarded no vehicle or the following vehicle(s):

___________________________________________________.

The Respondent is awarded no vehicle or the following vehicle(s):

___________________________________________________.

Each party shall pay all obligations including loans, insurance and/or taxes on

the vehicle(s) he/she is awarded. Each party shall refinance any outstanding debts on the vehicle that

he/she is awarded within_______days.

C. (H)Bank Accounts

The parties have divided any and all bank accounts and each shall keep the

accounts in his/her name.

OR

The Petitioner is awarded the following accounts:

Name on Account

Name of Bank

Balance

Checking

Savings

Checking

Savings

Checking

Savings

The Respondent is awarded the following accounts:

Name on Account

Name of Bank

Balance

Checking

Savings

Checking

Savings

Checking

Savings

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D. (I)Personal Property/Household Goods

The parties have divided all personal property/household goods and each

shall keep the property in his/her possession.

OR

The Petitioner is awarded the following personal property/household goods:

The Respondent is awarded the following personal property/household

goods:

E. (J)Retirement

Neither party has any retirement funds.

Each party shall keep his or her own retirement funds.

F. (K)Other Marital Property

The Petitioner is awarded:

The Respondent is awarded:

VI. (L)DEBTS

There are no marital debts.

OR

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The marital debts have been fairly divided between the parties and each shall pay the debts

currently in his/her name.

OR

The following debts are assigned to the Petitioner and he/she shall hold the Respondent

harmless for payment thereon:

The following debts are assigned to the Respondent and he/she shall hold the Petitioner

harmless for payment thereon:

VII. (M)EQUITABLE DIVISION OF PROPERTY

The parties agree that the division of property and debts is equitable.

OR

In order to make the division of property and debts equitable, Petitioner or

Respondent

shall pay the other party $________________ within ______ days of the signing of this Agreement. (amount)

VIII. (N)MAINTENANCE

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Neither party shall be responsible for paying maintenance to the other.

OR

The Petitioner Respondent shall pay the other party maintenance in the amount of

$_______________ per month on the first day of the month, beginning _________________ until (amount) (beginning date)

__________________, the death of either party, the remarriage of the party receiving maintenance, (ending date)

or the cohabitation of that party with a non-related adult, whichever occurs first.

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In signing below, the parties acknowledge that this is a fair agreement, that they understand

its provisions, understand that it is a legal binding document, and are entering the agreement freely.

(O) (P) ______________________

(Signature of Petitioner) (Signature of Respondent)


)



___________________, 200____.


NOTARY PUBLIC



)



___________________, 200____.


NOTARY PUBLIC


Revised: 7/18/2007

1



(B)__________________________ PETITIONER


SELF-HELP FORM #4

v. DEPOSITION OF PETITIONER

(C)__________________________ RESPONDENT


* * * * * * * * *

The Petitioner, being duly sworn, states:

I. I am the Petitioner in this matter.

II. I had been a resident of Kentucky for more than 180 days when I filed my Petition.

III. My age is ________.

IV. My employment status is: unemployed disabled retired employed as

____________________________. (type of occupation)

V. My spouse’s age is ________.

VI. My spouse’s employment status is: unemployed disabled retired employed

as ____________________________ (type of occupation)

VII. We were married on ____________________________ in ____________________ (date of marriage) (county)

County, ___________________. (state)

VIII. We separated on (D)__________________________ and have not lived together as (date of separation)

husband and wife since then.

IX. We have no minor children of our marriage.

OR

Revised: 7/18/2007

2

(E)We have the following minor child(ren) of our marriage: Initials

Age

X. I am not the wife is not pregnant.

XI. Our marriage is irretrievably broken. There is no reasonable hope of reconciliation

and a conciliation conference would serve no useful purpose.

XII. Neither of us is in the military.

XIII. The Respondent is in default.

OR

We have entered a marital separation agreement that has been filed with the Court.

XIV.(F)I am the wife. I want do not want my former name of___________________ (former name)

to be restored.

(G)

(signature of Petitioner)

(H)

(Print name of Petitioner)

(address)

(I)

(telephone)

Revised: 7/18/2007

3


)



___________________, 200____.


NOTARY PUBLIC


Revised: 7/18/2007

1



(B)__________________________ PETITIONER


SELF-HELP FORM #4A

v. REQUEST FOR RESTORATION OF FORMER NAME

(C)__________________________ RESPONDENT


* * * * * * * * *

The respondent states:

1. I, ___________________________, am the respondent in this action for dissolution of

marriage.

2. I request that the decree of dissolution of marriage restore me to my former name,

____________________________.

______________________________

SIGNATURE OF RESPONDENT



)



___________________, 200____.


NOTARY PUBLIC


Revised: 7/18/2007

1



(B) __________________________ PETITIONER


SELF-HELP FORM #5A

v. FINDINGS OF FACT AND

DECREE OF DISSOLUTION OF MARRIAGE

(Without Children Under 18, With Agreement)

(C) __________________________ RESPONDENT


* * * * * * * * *

This action came before the Court on a petition for dissolution of marriage. The parties

entered a Marital Settlement Agreement, and the Respondent signed an Appearance and Waiver,

which is on file with the Court. The Petitioner tendered proof by written interrogatories.

Accordingly, the Court finds that:

1. The Petitioner and/or the Respondent have resided in Kentucky for more than

180 days preceding the filing of the petition.

2. The parties were married on __________________ in _______________________ (date of marriage) (county)

County, _________________, where the marriage is registered. (state)

3. The parties have lived apart for more than 60 days.

4. The marriage is irretrievably broken and the conciliation provisions of KRS 403.170

do not apply.

5. No children were born of the marriage.

OR

Revised: 7/18/2007

2

No children were born of the marriage who are under 18 years of age and/or still in

high school.

6. The wife is not pregnant.

7. The parties have entered a Marital Settlement Agreement, which was filed with the

Court. The Court has reviewed the agreement and finds it to be not unconscionable.

On the basis of these findings,

IT IS HEREBY ORDERED AND ADJUDGED THAT:

1. The marriage between the Petitioner, _____________________________, and the (name of Petitioner)

Respondent, _________________________________, of ________________________________ (name of Respondent) (date of marriage)

is dissolved.

2. The Marital Settlement Agreement filed with the Court in this case is incorporated by

reference as if fully set out here word for word and the parties shall perform according to its terms.

3. The wife is restored to her former name, ____________________________. (wife’s former name)

OR

The wife does not seek restoration to a former name.

4. There being no just cause for delay, this is a final decree.

JUDGE

JEFFERSON CIRCUIT COURT

FAMILY DIVISION ______

DATE:

Revised: 7/18/2007

3

(D) Signature of person filing

Findings of Fact and Decree

(E) Printed name of person filing


Address

(F) Telephone Number


(G) COMMONWEALTH OF KENTUCKY )

)



___________________, 200____.


NOTARY PUBLIC


Revised: 7/18/2007

4

CERTIFICATION


telephone number of the other person(s) involved in this action as listed below is:

___________________________

(H) Name of other party

___________________________


___________________________

City, State, ZIP

___________________________

Telephone number

I have filed this Findings of Fact and Decree with the Clerk of the Jefferson Circuit Court,

Family Division, and have mailed a copy to the other party involved in this action.

(I) Signature

Date

Revised 7/18/2007

1



(B) __________________________ PETITIONER


SELF-HELP FORM #6

v. MOTION FOR DEFAULT JUDGMENT

AND DECREE OF DISSOLUTION OF MARRIAGE

(C) __________________________ RESPONDENT


* * * * * * * * *

TO:

(name of spouse)

(address of spouse)

(D)Please take notice that, at ___________ ___.m. on ___________________, __________, (time) (a./p.) (date) (year)

in the courtroom of the above Court, I shall make the motion and tender the order set out below.

MOTION

The Petitioner, _____________________________, comes without counsel and moves the (name of Petitioner)

Court to enter a Default Judgment and Decree of Dissolution. A Default Judgment certificate and

Military Affidavit is attached.

2

(E) Signature of person filing

Motion for Default Judgment

(F) Printed name of person filing

Motion for Default Judgment

Address

(G) Telephone Number

CERTIFICATION



____________________________


____________________________


____________________________

City, State, ZIP

____________________________

Telephone number

I have filed this Motion for Default Judgment with the Clerk of the Jefferson Circuit Court,


(I) Signature

Date

Revised 7/18/2007

1



(B) __________________________ PETITIONER


v. DEFAULT JUDGMENT CERTIFICATE AND MILITARY AFFIDAVIT

(C) __________________________ RESPONDENT


* * * * * * * * *

I certify that:

1. No papers have been served on me by the Respondent in default.

(J) 2. The Respondent was personally served by

A. Certified mail on _____________________________________. (date Respondent picked up certified mail)

Sheriff on _____________________________________. (date Respondent served)

Twenty days have elapsed since the date of service

OR

B. A Warning Order Attorney was appointed on _______________________ (date Warning Order Attorney appointed)

and filed a report with the Court on _______________________________. (date Warning Order Attorney filed)

Fifty days have elapsed since date of appointment of Warning Order Attorney.

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2

3. The Respondent is not now nor has he/she been at any time during the pendency of

this action engaged in active duty of any branch of the United States military service.

_______________________________

(K)(signature of Petitioner)

(L)COMMONWEALTH OF KENTUCKY )

)



___________________, 200____.


NOTARY PUBLIC


1



(B) __________________________ PETITIONER


v. DEFAULT JUDGMENT

(C) __________________________ RESPONDENT


* * * * * * * * *

Motion having been made and the Court being sufficiently advised,

IT IS HEREBY ORDERED that the Respondent, having neither made any response nor

entered an appearance, is in default and this matter is scheduled for a hearing at __________ ____.m. (time) (a./p.)

on the ________ day of _______________, ______, for the purpose of taking proof and entering a (date) (month) (year)

Decree of Dissolution of Marriage.

JUDGE



DATE:

cc: Petitioner

Respondent

Revised: 7/18/2007

1



(B) __________________________ PETITIONER


SELF-HELP FORM #6

DECREE OF DISSOLUTION OF MARRIAGE

(With Default Judgment Entered)

(C) __________________________ RESPONDENT


* * * * * * * * *

This action came before the Court on a Petition for Dissolution of Marriage. Respondent

was served and has made no response. Petitioner has filed the Default Judgment Certificate and

Military Affidavit with the Court, and has tendered proof under oath. The Court finds that:

1. The Petitioner and/or the Respondent has/have resided in Kentucky for more than

180 days preceding the filing of the petition.

2. The parties were married on __________________ in _______________________ (date of marriage) (county)

County, _________________, where the marriage is registered. (state)

3. The parties have lived apart for more than 60 days.

4. The marriage is irretrievably broken and the conciliation provisions of KRS 403.170 do

not apply.

5. The wife is not pregnant.

6. The Respondent has made no response and has not entered an appearance, and is in

default.

Revised: 7/18/2007

2

On the basis of these findings,

IT IS HEREBY ORDERED AND ADJUDGED THAT:

1. The marriage between the Petitioner, _____________________________, and the (name of Petitioner)

Respondent, _________________________________, of ________________________________ (name of Respondent) (date of marriage)

is dissolved.

2. All property has been divided between the parties and this division is fair and

equitable. Each Party will keep the property in his/her possession

OR

Property shall be divided as follows:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. There are no joint debts and each party will pay the debts in his/her name.

OR

Debts will be divided as follows:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4. The wife is restored to her former name, ___________________________. (wife’s former name)

OR

The wife does not seek restoration to a former name.

Revised: 7/18/2007

3

5. There being no just cause for delay, this is a final decree.

JUDGE



DATE:





Address


(G) COMMONWEALTH OF KENTUCKY )

)


The foregoing instrument was subscribed, sworn to and acknowledged before me on

____________________, 200____, by _________________, to be his/her free act and will.


Notary Public

State at Large, Kentucky

Revised: 7/18/2007

1

CERTIFICATION


telephone number of the other person(s) involved in this action as listed below is:

____________________________


____________________________


____________________________

City, State, ZIP

____________________________

Telephone number

I have filed this Findings of Fact and Decree with the Clerk of the Jefferson Circuit Court,


(I) Signature

Date

Revised 7/18/2007

1


FAMILY DIVISION (B) _________

__________________________ PETITIONER


SELF-HELP FORM #7

v. AFFIDAVIT FOR WARNING ORDER ATTORNEY

_________________________ RESPONDENT


* * * * * * * * *

The Petitioner, __________________________, being first duly sworn, states:

1. That the Respondent has so concealed himself/herself that a Summons cannot be served upon

him/her.

2. That the Respondent’s last known address is (Fill in the complete address including the zip

code): _______________________________________________________________________

The Petitioner respectfully requests this Court to appoint a Warning Order Attorney.

**Must be signed in the presence of a Notary**

Petitioner’s Signature

Date:


)


Subscribed and sworn to before me by the above-named Petitioner this _______ day of

____________________, 200 ____.


Notary Public

State at Large, Kentucky

Revised: 7/18/2007

1



(B) __________________________ PETITIONER


SELF-HELP FORM #8

v. NOTICE-MOTION TO MOVE CASE FORWARD

(C) __________________________ RESPONDENT


* * * * * * * * *

TO:

(name of spouse)

(address of spouse)

Please take notice that, at ____________ ___.m. on ___________________, __________, (time) (a./p.) (date) (year)

in the courtroom of the above Court, I shall make the motion and tender the order set out below.

MOTION

The Petitioner comes without counsel and moves the Court to enter an order sufficient to

move this case forward. I filed my petition for divorce on _______________________________. (date petition filed)

My spouse has has not been served with the petition and summons.

Revised: 7/18/2007

1


Motion to Move Case Forward


Motion to Move Case Forward

Address


CERTIFICATION



______________________________

(G) Name of other party

______________________________


_______________________________

City, State, ZIP

_______________________________

Telephone number

I have filed this Motion to Move Case Forward with the Clerk of the Jefferson Circuit Court,


(H) Signature

Date

Revised: 7/18/2007

1

NO. (A) JEFFERSON CIRCUIT COURT

FAMILY DIVISION

(B) PETITIONER

(print name of petitioner)

SELF-HELP FORM #9

V. MOTION-ORDER TO PROCEED WITHOUT PAYING COURT COSTS

(C) RESPONDENT

(print name of spouse)

* * * * *

MOTION

The petitioner comes without counsel and moves the Court to enter the following order. The

petitioner’s affidavit is attached.

____________________________________

(D) (signature of petitioner)

(E) (Address)

(F) Phone

ORDER

Motion having been made and being supported by affidavit,

IT IS HEREBY ORDERED that the petitioner may prosecute this action through its

conclusion without payment of costs.

______________________________ __________________________________________

DATE JUDGE

Revised: 7/18/2007

2

NO. (G) JEFFERSON CIRCUIT COURT

FAMILY DIVISION

(H) PETITIONER

(print name of petitioner)

V. AFFIDAVIT TO PROCEED IN FORMA PAUPERIS

(I) RESPONDENT

(print name of spouse)

* * * * *

I, (J) , state under oath that:

(name of petitioner)

1. I am the petitioner in this case.

2. On account of my poverty, I am unable to pay the cost of this proceeding.

3. (K) I have child(ren)/ no child(ren) dependent on me for support.

(number)

4. (L) I am disabled unemployed retired employed full-time

part-time, earning $ per hour for hours per week.

(amount) (number)

5. (M) My monthly income consists of:

gross earnings $

K-TAP $

food stamps $

child support $

Social Security (retirement) $

Social Security Disability $

SSI $

other $

Revised: 7/18/2007

3

6. (N) Apart from basic furniture and clothing, I own these assets:

real estate or trailer at

none

(address)

worth $ (value minus debt)

(amount)

car: none

(year and model)

worth $ (value minus debt)

(amount)

savings: $ none

(amount)

other: $ none

(amount)

(O) (signature of petitioner)


)


Subscribed and sworn to before me by the above-named petitioner on this day of

, .

My commission expires: .

NOTARY PUBLIC


Revised: 7/18/2007

4



(B)________________________ PETITIONER

(PRINT NAME OF PETITIONER) (SELF-HELP FORM #10) V. NOTICE-MOTION-ORDER TO SCHEDULE HEARING

(C)________________________ RESPONDENT

(PRINT NAME OF SPOUSE)

* * * * *

TO: __________________________ (NAME AND ADDRESS OF SPOUSE)

___________________________________

___________________________________

(D) PLEASE TAKE NOTICE that, at ____________________ ____.m. on _________, (time) (a./p.) (date) ______, in the courtroom of the above Court, I shall make the motion and tender the order set out (year)

below.

MOTION

The petitioner, _______________________, comes without counsel and moves the Court to

schedule a hearing for the purpose of resolving any issues, taking proof, and entering a decree of

dissolution of marriage. The respondent has been served with the petition filed a response

entered his appearance and waiver (check whichever applies) but the parties have not entered into a

marital settlement agreement.

__________________________________________

(E) (Signature of person filing motion for hearing)

Revised: 7/18/2007

5

__________________________________________

(F) (Printed name of person filing motion for hearing)

__________________________________________ (Address) __________________________________________

__________________________________________

(G) (Telephone Number)

CERTIFICATE

I hereby certify that I mailed a copy of this notice, motion, and proposed order on this

________ day of ______________________, ___________, to (Name and address of Respondent)

____________________________________________________________________________________________

_______________________________________________________________________________________________________.

__________________________________________

(H) (SIGNATURE)

Revised: 7/18/2007

6

NO. (H)____________________ JEFFERSON CIRCUIT COURT


(I)________________________ PETITIONER

(PRINT NAME OF PETITIONER) (SELF-HELP FORM #10) V. ORDER

(J)________________________ RESPONDENT

(PRINT NAME OF SPOUSE)

* * * * *

Motion having been made and the Court being sufficiently advised, a hearing in this case is

scheduled at ______ a.m./p.m. on the ____ day of ____________________, _______, for the

purpose of resolving any issues, taking proof, and entering a decree of dissolution of marriage.

____________________________________ ____________________________________

DATE JUDGE

CC: Petitioner

Respondent

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