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    1076-0094_Application-Dissolution-Marraige_Exp.11.30.2024_504

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    Nihar Ranjan
    Divorce

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    © All Rights Reserved
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    1076-0094_Application-Dissolution-Marraige_Exp.11.30.2024_504

    Uploaded by

    Nihar Ranjan
    2 views2 pages
    Divorce

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Divorce

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2 views2 pages

    1076-0094_Application-Dissolution-Marraige_Exp.11.30.2024_504

    Uploaded by

    Nihar Ranjan
    Divorce

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Page 1 of 2 OMB Control Number 1076-0094

    Expires: 11/30/2024

    APPLICATION FOR DISSOLUTION OF MARRIAGE

    Pursuant to 25 CFR 11.606 (c) the petitioner files this verified petition for the dissolution of
    marriage between the plaintiff and respondent:

    Petitioner_________________________ Address ____________________________


    Age ____ Occupation _____________________ Length of residence __________

    Respondent_________________________ Address ___________________________


    Age ____ Occupation ________________________ Length of residence __________

    Date of marriage__________ Place marriage was registered_____________________

    Does the petitioner stipulate that the marriage is irretrievably broken in that either: (1) the parties
    have lived separate and apart for a continuous period of more than 180 days or (2) there is a serious
    marital discord adversely affecting the attitude of one or both of the parties toward the marriage and there
    is no reasonable prospect of reconciliation? ____ Yes ____ No

    List all living children of the marriage:

    _____________________________ ____ _____________________________________


    Name Age Address
    _____________________________ ____ _____________________________________
    Name Age Address
    (Continue on separate sheet if necessary)

    Is the wife pregnant? ____ Yes ____ No

    Describe any arrangements relative to the support of the children (including visitation rights and
    provision for custody) and spousal maintenance:____________________________________
    __________________________________________________________________________
    (Continue on separate sheet if necessary)

    (Continued on next page)


    Page 2 of 2 OMB Control # 1076-0094
    Expires: 11/30/20240

    VERIFICATION
    I, _______________________________, Petitioner, being duly sworn to tell the truth and being of lawful
    age, hereby, state that I have prepared and read the factual information provided above and I declare
    under penalty of perjury that the foregoing is true and correct to the best of my personal knowledge.

    ___________________________________
    Signature

    Subscribed and sworn to before me this ____ day of ____________________, 20__.

    (SEAL)

    _____________________________
    Court Clerk

    PRIVACY ACT NOTICE


    This information is subject to the Privacy Act.

    PAPERWORK REDUCTION ACT STATEMENT


    This information is being collected to assist eligible Indian individuals to obtain a decree for dissolution of marriage.
    You are not required to respond to this collection of information unless it displays a current and valid OMB control
    number. This information will be used to determine the jurisdictional authority of the Court of Indian Offenses and the
    eligibility of the petitioner for a decree for dissolution of a marriage. Responses are required to obtain a benefit (the
    decree requested). Public reporting burden for this form is estimated to average 15 minutes per response, including
    the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct
    comments regarding the burden estimate or any other aspect of this form to: Information Collection Clearance Officer
    – Indian Affairs, 1849 C Street, NW, MS 4660, Washington, DC 20240 or [email protected].

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