I am the:    Husband    Wife 

Wife Information Section:

Current full legal Name:

Full Maiden Name of Wife:

Does Wife wish to resume use of maiden name?  List No Yes Don't Know

Social Security Number of Wife:

Driver's License Number of Wife (if known): 

Place of Birth:

Date of Birth:

Race:          In Military: List No Yes Don't Know

Number of this Marriage: List First Second Third Fourth Fifth

Education Level of Wife: List None First Grade Second Grade Third Grade Fourth Grade Sixth Grade Seventh Grade Eigth Grade Ninth Grade Tenth Grade Eleventh Grade High School Graduate 1 year college 2 years college 3 years collage College Graduate Five Plus Years College

Is current Address of Wife known at this time: List Yes No

Current or Last known Residence Address:

                    Number and Street:

                    City and State or Country:   Zip code:

                    County of this Address:

                    Pay Taxes in Virginia? List Yes No Don't Know

Length of time at this address: 

Phone Number:     Cell Phone:     Work Phone:

email address:    

Husband Information Section:

Current full legal Name:

Social Security Number of Husband:

Driver's License Number of Husband (if known): 

Place of Birth:

Date of Birth:

Race:          In Military: List No Yes Don't Know

Number of this Marriage: List First Second Third Fourth Fifth

Education Level of Husband: List None First Grade Second Grade Third Grade Fourth Grade Sixth Grade Seventh Grade Eigth Grade Ninth Grade Tenth Grade Eleventh Grade High School Graduate 1 year college 2 years college 3 years collage College Graduate Five Plus Years College

Is current Address of Husband known at this time: List Yes No

Current or Last known Residence Address:

                    Number and Street:

                    City and State or Country:   Zip code:

                   County of this Address:

                    Pay Taxes in Virginia? List Yes No Don't Know

Length of time at this address: 

Phone Number:     Cell Phone:     Work Phone:

email address:    

Marriage Information Section:

City of Marriage:      State or Country of Marriage:

Date of Marriage:     Date of Separation:

Is there a Separation Agreement? Select Yes No

If yes, list date of Agreement:

Number of Children born or adopted of both Husband and Wife: List None 1 2 3 4 5 6 7 8 9 10

Child 1 Name:      DOB:      Social Security No:

Child 2 Name:      DOB:      Social Security No:

Child 3 Name:      DOB:      Social Security No:

Child 4 Name:      DOB:      Social Security No:

Child 5 Name:      DOB:      Social Security No:

(Please enter additional child information in comments section below)

Last Address of Cohabitation: List Wife's Current Address Husband's Current Address Other (Please list below)

Number and Street:

City and State or Country:   Zip code:

Enter additional information or comments in the space provided below:

What is your prefered method of contact:  List No Preference First Cell Phone then Home Phone First Home Phone then Cell Phone Home Phone Cell Phone Work Phone email Letter

By checking this box as an electronic signature, I hereby certify that all the information contained herein is true, correct and complete to the best of my knowledge and belief.  Furthermore, I agree to inform attorney as to any change in information as the case progresses.