ANNULMENT INFORMATION SHEET. Date of Consultation: Referred by: (today s date) Social Security# (last 4 digits only)
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1 The Law Offices of Shelly B. West Three Energy Square 6688 North Central Expressway, Suite 1000 Dallas, Texas consult $ ANNULMENT INFORMATION SHEET Date of Consultation: Referred by: (today s date) PETITIONER: (If you are filing a new case you are the Petitioner.) Full Name: Maiden Name: Birthdate: Place of Birth: Age: Social Security# (last 4 digits only) D.L. # (last 4 digits only) State: Home Address & County: Telephone Numbers: (Work): (Home): Other numbers: (Cell): (Fax): Business Name: Business Address: Address: Salary/Income: RESPONDENT: (If you are responding to a case that was filed against you, you are the Respondent.) Full Name: Maiden Name: Birthdate: Place of Birth: Age: Social Security# (last 4 digits only) D.L. # (last 4 digits only) State: Home Address & County: Telephone Numbers: (Work): (Home): Other numbers: (Cell): (Fax): Business Address: Page 1
2 Address: Salary/Income: Next of Kin: Phone: MARRIAGE: Date of Marriage: Separation Date: Place of Marriage: Would you like a name change: CHILDREN FROM THIS MARRIAGE UNDER 18: Name S.S. Number Sex Birthdate Birthplace (Last 4 digits only) Temporary Orders Desired? Extraordinary Relief Desired? Change of Name Desired? To What? Request Award of Attorney s Fees? Waiver or Service? Property Division: Why do you feel you might qualify for an annulment? Who is/are the child(ren) living with now and for what period of time: Have you been to court before in this matter? When and Why? Page 2
3 Cause No. (Case No.) and County of case (Please provide the latest order) Have many times have you been married? (Include any marriages annulled) Have you ever been charged or convicted with a misdemeanor? If yes, please explain Have you ever been charged or convicted with a felony? If yes, please explain At what age did you graduate from high school? PROPERTY REAL PROPERTY: Legal Description: When Acquired: Purchase Price: Present Value: REAL PROPERTY: Legal Description: When Acquired: Purchase Price: Present Value: VEHICLES: FINANCIAL INSTITUTIONS: Page 3
4 Account Balance: Account Balance: Account Balance: RETIREMENT ACCOUNTS: DEBTS: Page 4
5 CAUSE NO. IN THE MATTER OF (INTEREST OF ) IN THE DISTRICT COURT OF DALLAS COUNTY, TEXAS AND JUDICIAL DISTRICT HEALTH INSURANCE AVAILABILITY FORM Attention: This information must be filed with the court BEFORE first hearing. See TEX FAM CODE (b). NAME OF PARTY: MOVANT RESPONDENT PARTY S ATTORNEY (IF ANY): BESIDE THE NAME OF EACH CHILD, CHECK ALL TYPES OF HEALTH INSURANCE OR HEALTH CARE BENEFITS CURRENTLY COVERING THE CHILD(REN). YOU MAY CHECK MORE THAN ONE SOURCE. EMPLOYER PROVIDED NAME DOB SSN (LAST 4 DIGITS) FATHER S MOTHER S PRIVATE CHIP OTHER NONE FOR EACH INSURANCE SOURCE PLEASE LIST THE FOLLOWING INFORMATION: (ATTACH ADDITIONAL FORMS FOR EACH SOURCE OF BENEFITS) A. NAME OF CARRIER B. GROUP POLICY ID NUMBER C. POLICYHOLDER NAME & ID NUMBER D. NAME OF COVERED CHILD E. COST/MONTH OF COVERAGE [CHILD{REN) ONLY] $ (To determine coverage cost for child(ren), determine total cost for family coverage and subtract from this amount the cost to insure all covered individuals except the children.) F. ARE YOU CURRENTLY PAYING THE PREMIUMS FOR LISTED MEDICAL BENEFITS? YES NO STATE YOUR NET MONTHLY INCOME FROM YOR FINANCIAL INFORMATION STATEMENT: $ SIGNATURE OF PARTY COMPLETING FORM DATE PRINTED NAME HEALTH INSURANCE AVAILABILITY FORM PAGE OF FORM HIAF 11/01 Page 5
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To: Gold Coast Cremation From: Phone: : Fax: 951-667-1611 Date: Total Pages Being Submitted: This paperwork is regarding (Check one): Advance Planning Imminent Death Death Has Occurred My Loved One is
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GW Rental Management LLC *Please read before filling out rental application*
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Request for Group Coverage/Enrollment Form
Employee Benefit Trust 1205 Windham Parkway Romeoville, IL 60446 800.807.9460 / 630.378.3005 fax Request for Group Coverage/Enrollment Form Due to the Health Insurance Portability and Accountability Act
SUBURBAN UROLOGY ASSOCIATES Please Print
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CHECK LIST FOR OBTAINING REGISTERED CONTRACTOR S LICENSE
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Adjusted Net Monthly Income of Petitioner (Preliminary Average Monthly income minus monthly cash medical support ordered in this action) $
Rule 9.27 Guidelines Worksheets. Rule 9.27 Form 1: Guidelines Worksheet. FORM 1 CHILD SUPPORT GUIDELINES WORKSHEET Docket No: I. NET MONTHLY INCOME OF PETITIONER (NAME), [ ] Custodial Parent [ ] Noncustodial
Arapahoe Housing Authority
Arapahoe Housing Authority 208 Sixth Street, Box 0 Arapahoe, NE 68922 Telephone: (308) 962-7669 Fax: (308) 962-3669 Email: araphous@atcjet.net Office Use Only: Date of Application: Time of Application: