Domestic Relations Affidavit - Kansas Divorce and ….docxVIP

IN THE DISTRICT COURT OF _________________________ COUNTY, KANSASIN THE MATTER OF:andCase No. (PETITIONER’S)(RESPONDENT’S) DOMESTIC RELATIONS AFFIDAVITNow this day of , 200, comes the (Petitioner)(Respondent) and states:1. Wife/MotherDate of BirthSocial Security Number2. Husband/FatherDate of BirthSocial Security Number3. Marriage:DateCityCountyStateCountry4. Number of Marriages:PetitionerRespondent5. Number of children of this marriage or relationship: 6. Children of this marriage or relationship:NameSocial Security NoDate of BirthResiding WithChilds Assets------------------------------------------------------------------------------------------------- -------------------------7. Minor children of Father/Husband by other marriages or relationships and those attending college with his financial support. (Do not include step-children unless legally adopted by him).NameSocial Security NoDate of BirthResiding WithAmount Support------------------------------------------------------------------------------------------------- -------------------------8. Minor children of Mother/Wife by other marriages or relationships and those attending college with her financial support. (Do not include step-children unless legally adopted by her).NameSocial Security NoDate of BirthResiding WithAmount Support------------------------------------------------------------------------------------------------- -------------------------9.Spousal support, maintenance or alimony presently paid or received by either party:Obligor on SupportObligee on SupportAmount per MoDate of Termination of Support--------------------------------------------------------------------------------------------------------------------------10. Husband/Father is employed bywith an address ofPosition:Paid: (weekly)(every two weeks)(twice each month)(monthly)(other)Health Insurance:Does Health Insurance Cover Children? (Yes) (No)Dependent Coverage Cost: $ Is COBRA continuation coverage available?