APPALACHIAN RESEARCH & DEFENSE FUND OF KY

("APPALRED LEGAL AID")

Self-Help Divorce Packet INSTRUCTIONS for Couples WITH Children of this Marriage Who
Are Under the Age of 18 (No matter who they are living with or who has custody of them).

(Note: Children who have been adopted by you and your spouse during the marriage are also
considered “children of the marriage”)

These instructions will tell you how to complete the forms and file your divorce case with the
Court. Read over the instructions before you start, so you can gather the information you need to
complete the forms. Make sure ALL forms are printed on one side.

Each form has a number in the UPPER LEFT-hand corner of the form. These instructions will
take each form, in order, and explain how to complete it. You must use a black or blue pen (not a
pencil) to complete these forms.

Note: You will be able to submit most of these forms to the Court as soon as you complete them.
However, because you have children of the marriage, you will need to wait 60 days after filing
the Petition before filing the last four forms (these instructions will inform you which forms
these are).
______________________________________________________________________________

Coversheet

• Add parties, you are the petitioner, and your spouse is the adverse
• In the box labeled “Domestic Relations” check the box that applies to you, with or without
children

Form 1 (two pages):

This form is a Motion asking the Court to "waive" the divorce filing fee (If it is “waived”
you will not have to pay).

• On the top line, and on the top of ALL forms, print YOUR name (you will be addressed
as the "Petitioner" for the remainder of the forms).

• On the second line, and on the top of ALL forms, print your spouse's name (your
spouse will be addressed as the "Respondent" for the remainder of the forms).

• Complete the section entirely stating ALL personal information.

• State all Monthly Income and Expenses on the appropriate lines.

• Question #5, ADD together all monthly income given on the previous lines and give a
total. If none, put $0.

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 • Question #6, ADD together all monthly expenses given on the previous lines and give a
total. If none, put $0.

• State all Assets and Debts (next page) on the appropriate lines.

• Question #7, ADD together all total assets given on the previous lines and give a total. If
none, put $0.

• Question #8, ADD together all total debts given on the previous lines and give a total. If
none, put $0

• Sign the bottom block IN FRONT OF A NOTARY PUBLIC AND HAVE IT

NOTARIZED

Form 2 (one page):

This is the Order that will be signed by the judge, stating whether he or she is
waiving the filing fee.

• Only print your name, your spouse’s name and the name of the county you are filing the
case in.

Forms 3A and 3B (one page each):

These forms ("Case Data Information Sheets") are used by the clerks' office to
coordinate and cross-reference cases involving the same parties.

• On Form 3A enter complete information about you, your spouse, and

ANY CHILDREN (even if they are not children of the marriage) in your household.
Form 3B is "redacted" (information is eliminated or abbreviated to protect privacy).

• In the top middle of both forms, check the block for "Family Court.”

• The left hand column is YOUR personal information (because you are the
Petitioner). For "relationship to Respondent,” print “spouse".

• Under "other parties/children,” list any children living in your household, with their
personal information. Print the relationship to you.

• In the right hand column, print all personal information about your spouse.

•In the lower right corner of the page, complete personal information.

• Copy all the same information from Form 3A onto Form 3B (redacted form).

Form 4A and 4B (six pages each):

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 This is the Petition that formally begins your divorce case. The "A" form includes
all identifying information such as social security numbers and dates of birth, and
the "B" form "redacts" (removes) those identifying things, protecting your privacy.

• Print the county you are filing in on the line next to "Circuit Court.”

• IF you have a domestic violence order (a "protective order,” or “DVO"), put the
case number on the line next to "Domestic Violence Order#.”

• Complete ALL personal information entirely regarding you and your spouse for Form
4A and 4B.

• Question #2: Complete CURRENT personal information. Check the box

indicating whether or not you have lived in Kentucky continuously for the past
180 days (six months). If you have moved back and forth between states during
that time, then you have NOT lived in KY continuously for the past 180 days.

• Question #7: Enter the number of children you have WITH YOUR SPOUSE who are
under the age of 18 and complete all of their personal information.

• Question #8: Check whether the children live with you or your spouse, enter the address
that each of the children live at.

• Question #9: List any address the child or children have lived at in the past five years
and with whom they lived with.

• Question #10: If you have NOT been involved in prior court case involving any of your
children of this marriage, check the box indicating you have not participated in court. If
you HAVE been involved in a prior court case, check the box indicating you have
participated in.
Line A-Name of children involved in case
Line B-Check the box indicating what court that case was in “District, Circuit,
Juvenile, Family, or another.”
Line C-Enter case number.
Line D-Enter the county.
Line E-State the outcome.
Line F-State the current status (if it is completed or still open).

• Question #11: Check the best person to have custody of the children and which type of
custody you are requesting (joint custody or sole custody).

• Question #12: Tells the Court what type of arrangements have or have not been made for
visitation and custody of child support. Check the appropriate box indicating if
arrangements HAVE or have NOT been made yet.

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 • Question #13: Check the appropriate box of whom should pay child support.

• Question #14: Check the box indicating whether or not you ARE or ARE NOT pregnant.
(Note: YES you must answer this no matter your age!)

• Question #16: Check one of the boxes about MARITAL property and debts (“marital
property" and "debts" are ANY property either of you bought during marriage, no matter
which of you currently has possession of it; and any debt either of you took on during
your marriage, no matter which one of you signed for the debt).

• At the end of question #16, print YOUR name as Petitioner.

B. Maintenance: check the box WHETHER OR NOT either of you will

request that the other pay "maintenance" (“alimony"). (Note: The Court will
decide whether or not it is awarded).

C. Check the box indicating who should be required to pay child support.

D. IF you want you or your spouse to have sole custody or joint custody of the
children, check the desired box.

E. Check the box to the left of whether the child or children should live with you
or your spouse.

I. IF you want to change your name back to your former name, check the box to
the left and print the name that you want to have.

• Print your name on bottom line. DO NOT SIGN THIS FORM UNTIL YOU SIGN
IT IN FRONT OF A NOTARY PUBLIC!

• Give a copy of this Petition to your spouse.

Form 4B: This is the "redacted" Petition. Copy everything from Form 4A onto 4B. DO NOT
SIGN THIS FORM UNTIL YOU SIGN IT IN FRONT OF A NOT ARY PUBLIC.

Form 5: Simplified Preliminary Disclosure Statement. This form tells the Court about your
financial situation — your property, income, debts and expenses.

• At the top heading of the form, check the box “Preliminary."

• In the box to the right, print the word "Family" next to the word “Court,” and print
the name of the county where you are filing your divorce.

• Check the box to the left of the word "Petitioner" (under the lines where you
have printed the names of the parties).

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• Under "Identifying Information of Both Parties" and "Income and Employment
Information of both parties,” Print personal information for you and your spouse.

• Under Children’s information, enter the number of children you and your spouse have
together and their personal information that is being requested.
• For B, estimate the monthly amount that you pay to a daycare provider, and the name of
which of you pay.

• For C, estimate monthly medical, dental, and vision insurance.

• If either you or your pay court-ordered child support for a child NOT OF THIS
MARRIAGE, list which of you make these payments, monthly amount, and the personal
information of the child.

• Under Summary of Assets & Debts: Check the applicable boxes to the right.
(Note: "real estate" is a house; if you own a mobile home you should list that
under "other assets”).

• There are five sections where you must describe the property you checked "yes" to; for
each item, describe it, state who currently has it, estimate worth ("fair market value");
state if you owe any amount; if you are making monthly payments, and the monthly
payment. Subtract that amount from "fair market value" and enter on the line “net value
or equity." If you exceed five items, use a separate paper to describe the rest.

• At the sentence "Do you owe any debts?" Answer appropriately. If you marked “yes,”
describe (if more than five, list on a separate paper).

• In each section list the creditor, who is listed on the debt, the monthly payment, and the
current balance. For "premarital account,” the answer is "yes" IF either you or your
spouse had this debt BEFORE marriage.

• Add the balances and enter the amount next to "Total Debt Balances"

• "Are you claiming a right to maintenance?" Check the appropriate box. If “yes,"
complete the two column boxes for expenses; the court will use these to decide whether
or not to award you maintenance “alimony.”

• For "Common Expenses for Family" and "Your Personal Expenses”, estimate
monthly expenses and total the amounts in "Grand Total.”

•DO NOT SIGN THIS UNTIL YOU ARE IN FRONT OF A NOTARY PUBLIC.

• Under the heading "CERTIFICATE OF SERVICE” check the box indicating how
you will give a copy to your spouse (REQUIRED). Sign the signature line, check
the box next to "Petitioner" and print your personal information.

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Form 6: Entry of Appearance and Waiver

• The Respondent must sign, saying that he or she has read the Petition and is OK with
the Court going forward with this divorce, and giving up rights to have an attorney. This
must be signed IN FRONT OF A NOTARY PUBLIC.
Form 7: Marital Settlement Agreement You and your spouse will need to sign in front of a
Notary Public. Print ALL personal information!

• On the top line print the name of the county you are filing your divorce.

• # III: list the names of all children of the marriage and their dates of birth.

• # V: Custody if you and your spouse agree that you should have “joint custody” of the
children check the appropriate box. OR, if you and your suppose agree only one should
have legal custody, check the box indicting which should have legal custody.

• # VI: Parenting Time if the children will be living with either you or your spouse most
of the time, check the appropriate box. OR, if you and your suppose agree to split an
equal amount, check the appropriate box and indicate how this will work.

• # XI: Child Support check the appropriate box indicating who will be paying child
support. If you and your spouse agree that child support should be set at the amount of
the usual guidelines, you SHOULD CONTACT THE CHILD SUPPORT OFFICE IN
YOUR COUNTY TO DETERMINE HOW MUXH CHILD SUPPORT WILL BE
PAID.

• Check the appropriate box indicating how often child support will be paid.
• If you and your spouse have agreed on an amount other than state
guidelines, explain why.
• If you and your spouse agree that no support will be paid because the one
paying cannot afford it, check the appropriate box.

• # XII: Health Insurance if children of the marriage are covered for health insurance by
KCHIP or Medicaid check the box. IF NOT, check who will provide health insurance
and the amount of the extraordinary medial expenses each of you will be responsible for.

• # XIII: Dependent Exemption check the box indicating who will be claiming the
children as dependents for tax purposes. OR, if you plan to share the tax credit, explain
how it will be divided.

• # XIV: Non Marital Property (property that either you or your spouse owned BEFORE
you were married, no matter who is using it now).

• If neither owns any non-marital property check the appropriate box. Or, if you
have non-marital property that you will be keeping, describe it.

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 • If your spouse has any non-marital property that he or she will be keeping,
describe it on the lines provided.

• # XV: Marital Property (property bought during the marriage).

• A. Real Estate ("real estate" is a house, whether or not you or your spouse are
living in it). If you and/or your spouse DID NOT buy during marriage, or if
either/both of you bought one but no longer own it, check the box ‘The parties
own no marital real estate.’

• OR, if either/both of you DID buy a house during this marriage and plan to sell
after divorce, check the box that states the complete address of the house. On the
lines provided state how the proceeds will be split.

• OR, if you and your spouse agreed on who will get the house, check the
appropriate person. On the lines provided, state the address of the property, the
number of days you or your spouse are giving the other party to refinance the
house, or number of days giving the other party to pay for their share of the
property. If the party keeping the property IS NOT paying for his or her share,
check the box, or enter an amount that the person keeping the property WILL pay
to the other party.

• B. Vehicles If you will not receive a vehicle in this divorce, check the box "no
vehicle". If you WILL receive a vehicle, check the box "the following vehicle(s)"
and describe the vehicle (make, model, year, color). Make the same entries about
whether or not your spouse is receiving a vehicle. Then, state how much time (in
days) you are agreeing that the person receiving the vehicle has to refinance (if it
is being financed).

• C. Bank Accounts If you and your spouse have already divided bank accounts
check the box. OR, if you and your spouse agree to give any bank accounts to one
or the other, check the state what kind of account(s) this/these are, and what bank
they are with.

• D. Personal Property/Household Goods If you and your spouse have already

divided all personal property and household goods check the box. OR, if you are
receiving certain items through the divorce, check the appropriate box and
describe those items. Give the same information for your spouse.

• E. Retirement If neither you nor your spouse have retirement check the box.
OR, if you and/or your spouse have a pension but are planning to keep it, check
the second box.

• F. Other Marital Property If you or your spouse have any MARITAL (bought
during marriage) that is being awarded to the other, check the appropriate box and
describe it.

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 • # XVI. Debts
• If there are no marital debts (debts during the marriage) check the box. OR, if
there ARE marital debts that have been divided, check the box.

• If there are marital debts that will be taken on by you or your spouse,
describe those on the lines provided.

• EQUITABLE DIVISION OF PROPERTY: if both agree that the marital

property and debts have been divided fair, check the appropriate box.

• OR, if you and your spouse do NOT believe the property and debts are
divided fair, check the appropriate box. Check whether you or your spouse
will pay a certain amount to make the agreement fair. Enter the amount
and date payment will be made.

• # XVII Maintenance ("Alimony")

• If neither you or your spouse is asking for Maintenance, check the box. BE
AWARE, if you check this box, the Court may not allow you to change your
mind; you will most likely be giving up your chance to request “alimony."

• If you and your spouse are AGREEING that one of you will pay
maintenance, check the box indicating which of you will be PA YING and
the monthly payments with a beginning and ending date.

• THIS FORM MUST BE SIGNED IN FRONT OF A NOTARY PUBLIC

BY BOTH PARTIES!

STOP!
YOU HAVE NOT FILED EVERYTHING THAT YOU CAN FILE
FOR NOW! BECAUSE YOU HAVE CHILDREN OF THE
MARRIAGE, YOU MUST NOW WAIT 60 DAYS AFTER YOU
HAVE FILED THE PETITION BEFORE YOU CAN FILE THE LAST
FOUR FORMS!

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(THE LAST FOUR FORMS ARE THE “FINAL VERIFIED DISCLOSURE
STATEMENT”, THE “DEPOSITION OF PETITIONER”, THE “FINDING
OF FACTS AND DECREE OF DISSOLUTION OF MARRIAGE”, AND
THE “MOTION FOR FINAL DECREE”).
Form 8A: Affidavit of No Change in Circumstances
• Fill in the blank with your name as the petitioner and your spouse as adverse.
• Check mark petitioner
• 1. Insert date you filed the first 7 forms
• 2. Check the box if there was or was not any changes for either party.
• Sign form in front of a notary
• CERTIFICATE OF SERVICE fill out the information it is asking for then sign form in front of a notary.

Form 8B: Final Verified Disclosure Statement tells whether there have been any changes in
your information since you first filed your case.

• Check the box "Final Verified Disclosure Statement" and print the name of the Court
("Family") and County where you are filing.

• Complete all personal information entirely. Be sure to put your total gross income
BEFORE taxes or anything else is taken out.

• If you have had any court cases in the past year, give the name and case number of the
case(s) and briefly describe what it/they are about.

• On the next page, sign this form IN FRONT OF A NOTARY PUBLIC.

• Below "Certificate of Service,” state how you will or have given a copy of this Final
Verified Disclosure Statement to your spouse, give the date and address that used. Sign
this section and check the box to the left of the word “Petitioner." Print ALL personal
information.

Form 9: Deposition

• Print the County where you are filing your divorce case AND put the case number that
the clerk assigned to your case (you should have this on your copy of the Petition).

• Enter ALL personal information, boxes must be checked accordingly.

• # XIII: This packet assumes that you and your spouse have signed and filed a
Separation Agreement; check the box "We have entered a marital separation
agreement that has been filed with the Court.” (The box saying that the Respondent is
in default would be used if there were no agreement and no Response to the Petition.)

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 • # XIV: Check the box whether or not you want to be restored to your maiden name;
then print the name you want.

• This form must be signed IN THE PRESENCE OF A NOTARY PUBLIC.

Form 10: Findings of Fact and Decree of Dissolution of Marriage

• Print the County where you are filing and the case number.

• Complete ALL personal information and check ALL appropriate boxes.

• Question #7: If your settlement agreement states that child support will be calculated
according to the standard child support guidelines, check the appropriate box. OR, if you
have worked out a different amount, check “deviation from the child support guidelines
to be justified because” and print why different arrangements have been made. OR,
check if an order has already been established by the court.

• In the section IN IT HEREBY ORDERED AND ADJUDGED THAT: Once again,

complete ALL personal information entirely.

• LEAVE THE LINES FOR JUDGE, CIRCUIT COURT, AND DATE BLANK (the
judge will fill these out).

• Under the words 'Tendered By” sign IN FRONT OF A NOTARY PUBLIC!

• Under the Section “Certification,” print ALL personal information. (This states that you
have mailed a copy to your spouse, which you must do).

Form 11: Motion for Final Decree

• Print the county you are filing the divorce in and give case number.

• On the lines provided under the word “Notice,” enter the date (month, day and
year) and the time that you are filing it.

• Complete ALL personal information (DO NOT LEAVE ANY BLANKS).

• # 2: On the line provided, enter the date that you filed the Petition for this
divorce (which should be at least 60 days before you are filing this motion; look
for the filing date on the Petition you filed earlier).

• # 3: Enter the date you filed the Entry of Appearance that your spouse signed.

• Sign the form and print ALL personal information.

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• In the section “Certification,” print ALL personal information. Mail a copy of this form
to your spouse.

DO NOT CHANGE ANY INFORMATION ON ANY OF THESE FORMS AFTER

YOU HAVE SIGNED THEM IN FRONT OF A NOTARY PUBLIC!

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AOC-104 Doc. Code: CCCS
Rev. 12-20 NW
EA L TH OF KE
Case No. ____________________

NT
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COMM

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Page 1 of 1 lex
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justitia
Court ________________________

CO

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Commonwealth of Kentucky OF JUS

County ______________________
Court of Justice www.kycourts.gov
CIVIL CASE COVER SHEET Division ______________________

PLAINTIFF/PETITIONER

VS.

DEFENDANT/RESPONDENT

 Check here if YOU DO NOT HAVE AN ATTORNEY and are REPRESENTING YOURSELF
(a Self-Represented [Pro Se] Litigant)

Nature of the Case: Place an "X" to the left of the ONE case category that most accurately describes your
PRIMARY CASE. If you are making more than one type of claim, check the one that you
consider most important.

DOMESTIC RELATIONS TORT (Injury) CONSUMER

 Dissolution/Divorce with Children  Automobile  Automobile Loan
 Dissolution/Divorce without Children  Intentional  Credit Card
 Malpractice-Medical  Sale-Purchase Consumer Goods
 Paternity
 Malpractice-Other  Fraud
 Custody
_______________________  Personal Loan
 URESA/UIFSA  Sale-Purchase Consumer Services
 Premises Liability
 Visitation/Parenting Time  Other: ___________________
 Product Liability
 Voluntary Termination of Parental Rights ________________________
 Property Damage
 Involuntary Termination of Parental Rights
 Slander/Libel/Defamation APPEALS
 Adoption
 Other: __________________  Appeal from Administrative Agency
 Other: ____________________________
_______________________  Appeal from District Court
________________________________
 Other: ___________________
REAL PROPERTY ________________________
PROBATE / ESTATE  Property Rights
 Guardianship-Adult  Condemnation MISC CIVIL
 Guardianship-Juvenile  Forcible Detainer (Eviction)  Habeas Corpus
 Guardianship-Conservatorship  Forcible Entry  Non-Domestic Relations
 Foreclosure Restraining Order
 Probate-Testate (with a will)
 Other: __________________  Tax
 Probate-Intestate (without a will)
_______________________  Writs
 Petition to Dispense with Administration  Other: ___________________
 Name Change BUSINESS / COMMERCIAL ________________________
 Other: ____________________________  Business Tort
EMPLOYMENT
________________________________  Statutory Action  Employment-Discrimination
 Business Contract Dispute  Employment-Other
 Other: __________________  ________________________
_______________________ ________________________

Print Reset Form

FORM 1
AOC-026 Doc. Code: AFP
NW
EA L TH OF KE
Case No. ____________________
Rev. 10-18

NT
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COMM

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Page 1 of 3 lex
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justitia
Court ________________________

CO

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Commonwealth of Kentucky
OF JUS

County ______________________
000
Court of Justice www.courts.ky.gov MOTION FOR WAIVER OF COSTS AND FEES AND
TO PROCEED IN FORMA PAUPERIS; AFFIDAVIT; Division ______________________
KRS 453.190; CR 5.05(4) FINANCIAL STATEMENT; AND ORDER

PLAINTIFF/PETITIONER

VS.

DEFENDANT/RESPONDENT

Motion for Waiver of Costs and Fees: Affiant is unable to pay the costs and fees of this action and hereby requests that
the Court waive them and allow Affiant to proceed in forma pauperis.
Affiant hereby submits the following information in support of the above Motion.
NAME:
ADDRESS:

DOB: Telephone:( )

I. MONTHLY INCOME/MONTHLY EXPENSES

1. Are you employed? q Yes, full-time. q Yes, part-time. q No.
Employer name and address:

2. Marital status:_______________
If married, spouse’s name: ___________________________________
3. Number of dependents (children, elderly, or disabled): _____ Relationship: ___________________ Age(s): __________
4. If married, is spouse employed? q Yes q No. If yes, include spouse’s income and expenses below unless this is a
divorce proceeding.
Monthly Income Monthly Expenses
Gross salary (before deductions) $_____________ q Mortgage q Rent payment $_____________
Public/Gov't assistance: Utilities (electric/gas) $_____________
Food stamps/SNAP $_____________
Water/Sewer/Trash $_____________
TANF $_____________
$_____________ Food $_____________
K-TAP
KCHIP $_____________ Phone(s) (landline and/or cell) $_____________
LIHEAP $_____________ Internet $_____________
WIC $_____________ Cable/Satellite $_____________
Child Care Assistance $_____________
Transportation $_____________
Foster care $_____________
$_____________ Clothing/Shoes $_____________
Other ___________________
Social Security (SSI/SSD) $_____________ Vehicle payment(s) $_____________
Worker’s Compensation $_____________ Insurance (vehicle, health, house/renter’s) $_____________
Unemployment $_____________ Credit card payment(s) $_____________
Retirement/Pension $_____________
Unreimbursed childcare $_____________
Child support $_____________
$_____________ Tuition/student loans $_____________
Maintenance/Alimony
Stocks, trusts, bonds $_____________ Medical/Dental payments/installments $_____________
Student financial aid $_____________ Child support $_____________
Other _______________________ $_____________ Other _______________________ $_____________

5. TOTAL MONTHLY INCOME $

0.00 6. TOTAL MONTHLY EXPENSES $ 0.00
FORM 1
AOC-026
Rev. 10-18
Page 2 of 3

II. ASSETS / DEBTS

Assets Debts / Outstanding balances owed
Cash on hand $_____________ Home loan, if homeowner $_____________
Bank accounts
Vehicle loan(s) $_____________
Checking $_____________
Savings $_____________ Credit card(s) $_____________
Other ____________________ $_____________ Student loan(s) $_____________
Value of home (if homeowner) $_____________ Medical $_____________

Value of other real estate owned (please list) Other __________________________ $_____________
$_____________ Other __________________________ $_____________
$_____________ Other __________________________ $_____________
$_____________ Other __________________________ $_____________
Value of vehicle(s) in working order Other __________________________ $_____________
(1) Yr/Make _____________________ $_____________
(2) Yr/Make _____________________ $_____________
(3) Yr/Make _____________________ $_____________

Value of personal possessions (i.e.,jewelry, boat)

$______________
$______________
$______________
$______________

7. TOTAL ASSETS $______________

0.00 8. TOTAL DEBTS $_____________
0.00

9. Additional comments:

_____________________________ ____________________________________________
Date Affiant's Signature

____________________________________________
Affiant’s Name (print or type)

SUBSCRIBED AND SWORN TO before me this ________ day of __________________________, 2________

My Commission Expires: _________________________ ____________________________________________

Attesting Officer or Notary’s Signature
FORM 2
AOC-026 Doc. Code: OFP
EA L TH OF KE Case No. ____________________
Rev. 10-18 or OFD NW

NT
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COMM

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Page 3 of 3 lex
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justitia Court ________________________

CO

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C
Commonwealth of Kentucky
RT TI
OF JUS

County ______________________
Court of Justice www.courts.ky.gov MOTION FOR WAIVER OF COSTS AND FEES AND
TO PROCEED IN FORMA PAUPERIS; AFFIDAVIT; Division ______________________
KRS 453.190; CR 5.05(4) FINANCIAL STATEMENT; AND ORDER

ORDER

This case having come on the Court’s docket on a motion for waiver of fees and costs associated with this action and to
proceed in forma pauperis pursuant to KRS 453.190, and the Court having reviewed the foregoing Affidavit and Financial
Statement, and being otherwise sufficiently advised, IT IS HEREBY ORDERED AND ADJUDGED that the Motion to
Proceed In Forma Pauperis is:

q GRANTED. (Doc Code: OFP) Affiant is a poor person pursuant to KRS 453.190(2) as follows: (Check one)

q Affiant is unable to pay the costs and fees associated with this action without depriving himself or herself or his
or her dependents of the necessities of life, including food, shelter, or clothing. OR

q Affiant’s income is at or below 100% on the sliding scale of indigency established by the Kentucky Supreme Court.

OR

q DENIED. (Doc Code: OFD) Affiant is not a “poor person” pursuant to KRS 453.190(2). Affiant shall have thirty (30)
days to pay any required fees or costs to appeal this decision. If Affiant fails to pay the required fees or costs, or fails
to seek review, the matter shall be treated as though not timely filed. CR 5.05(4).

_____________________________ ____________________________________________
Date Judge's Signature

Print Reset Form

CS-71
(R. 3/10 )
921 KAR 1:400

COMMONWEALTH OF KENTUCKY

WORKSHEET FOR MONTHLY

CHILD SUPPORT OBLIGATION

http://chfs.ky.gov/dis/cse.htm An Equal Opportunity Employer M/F/D

Page 1 of 3
 INSTRUCTIONS FOR USE

1. Enter each parent’s gross monthly income [KRS 403.212(2)(a) through (d)]. Column A for custodial parent and
Column B for noncustodial parent.

2. Enter the amount actually paid for court ordered maintenance for prior spouse(s) plus the amount of maintenance
ordered in the current proceeding [KRS 403.212(2)(g)(1)] in the appropriate columns..

3. For each column, as appropriate, enter the amount of child support that is:

a. paid pursuant to a court/administrative order for prior-born children [KRS 403.212(2)(g)(2)];

b. paid, but not pursuant to a court/administrative order, for prior-born children for whom the parent is legally
responsible [KRS 403.212(2)(g)(3)]; and

c. imputed for prior-born children residing with the parent [KRS 403.212(2)(g)(3)].

4. Subtract any amounts on lines 2 and 3 from the amounts on line 1,for each column, if the result is less than 0,
enter 0.

5. Add the amounts on line 4 in columns A and B to obtain the combined monthly adjusted parental gross income.

6. Divide each of the amounts on line 4A and 4B by the total amount on line 5C. Enter the percentages. [NOTE: If
the noncustodial parent (NCP) has 100% of the combined monthly adjusted parental gross income, use the CS-
71.1 to calculate the child support obligation. KRS 403.211(7)(b) provides a reduction in gross income for the
entire amount of health insurance premiums incurred for the child(ren) when a parent has 100% of the combined
monthly adjusted parental gross income.]

7. Determine the base support obligation by referring to the Guidelines Table at the end of the form, using the
combined monthly adjusted parental gross income as entered on line 5C and the number of children for whom
the parents share a joint legal responsibility [KRS 403.212(7)].

8. Enter the monthly payment for child care costs [KRS 403.211(6)].

9. Enter the monthly payment for the child(ren)’s health insurance premium or cash medical support[KRS
403.211(7)(a)].

10. Add lines 7, 8 and 9 in column C. This is the total monthly child support obligation.

11. Multiply line 10C by 6A and 6B for the monthly obligation of each parent. These amounts include each parent’s
share of child care costs and health insurance premium costs if these costs were included on lines 8C or 9C.

12. If the NCP pays either of the amounts listed on lines 8C or 9C to the provider, enter that amount on line 12. If
the NCP pays both of these amounts, add these amounts together and enter the total on line 12B. [NOTE: If the
NCP is paying 100 percent of either or both of these costs, then the NCP subtracts this amount from his/her
monthly obligation, which reduces the amount he/she pays to the custodial parent (CP). Subtracting 100 percent
includes the NCP’s percentage of these expenses and also compensates the NCP for paying the CP’s percentage
of these costs].

13. Subtract line 12B from line 11B and enter the amount. This is the amount the NCP pays to the CP. To calculate
a weekly amount, multiply line 13 by 12 and divide by 52.

CS-71 (Rev. 3/10) Page 2 of 3

CASE NAME: _______________________________ FILE NUMBER: ___________________
COUNTY: ________________________

COMMONWEALTH OF KENTUCKY
WORKSHEET FOR MONTHLY
CHILD SUPPORT OBLIGATION
A. Custodial Parent B. Noncustodial Parent C. Both Parents
(CP) (NCP)
1. Monthly gross $ $
income
2. Deduction for $ $
maintenance
payments
3. Deduction for other $ $
child support for
prior-born children
4. Adjusted monthly $ $
income
5. Combined monthly $
adjusted parental
gross income
6. Percentage of % %
combined monthly
adjusted parental
gross income
0% 0%
7. Base monthly support $

8. Child care costs $

9. Child(ren)’s health $
insurance premium or
cash medical support
10. Total child support $
obligation
11. Each parent’s $ $
monthly child
support obligation
12. Subtract child care $
costs or health
insurance premiums
paid by NCP to the
provider
13. Amount the NCP $
pays to the CP

CS-71 (Rev. 3/10) Page 3 of 3

COMBINED
MONTHLY
SIX OR
ADJUSTED ONE TWO THREE FOUR FIVE
MORE
PARENTAL CHILD CHILDREN CHILDREN CHILDREN CHILDREN
CHILDREN
GROSS
INCOME
$0 $ 60 $ 60 $ 60 $ 60 $ 60 $ 60
100 60 60 60 60 60 60
200 70 70 70 70 70 70
300 80 80 80 80 80 80
400 90 90 90 90 90 90
500 100 105 110 115 120 125
600 120 125 130 135 140 145
700 140 156 161 166 171 176
800 160 203 208 213 218 223
900 180 261 266 271 276 281
1,000 195 303 325 330 335 340
1,100 212 324 384 389 394 399
1,200 229 346 433 446 451 456
1,300 246 367 460 504 510 515
1,400 262 392 491 554 576 582
1,500 277 417 522 588 642 650
1,600 293 437 548 618 674 717
1,700 308 458 574 647 706 755
1,800 322 478 599 675 736 788
1,900 336 495 620 699 763 816
2,000 350 512 642 723 789 844
2,100 364 529 663 747 815 872
2,200 376 546 684 771 841 900
2,300 389 563 706 795 868 928
2,400 401 580 727 819 894 956
2,500 413 597 749 843 920 984
2,600 424 614 770 867 946 1,012
2,700 435 630 790 889 970 1,038
2,800 445 646 809 911 994 1,064
2,900 455 662 829 934 1,019 1,090
3,000 465 677 849 956 1,043 1,116
3,100 475 693 868 978 1,067 1,142
3,200 485 709 888 1,001 1,092 1,168
3,300 495 725 908 1,023 1,116 1,194
3,400 506 741 928 1,045 1,140 1,220
3,500 516 757 947 1,067 1,164 1,246
3,600 526 773 967 1,090 1,189 1,272
3,700 536 790 988 1,113 1,215 1,299
3,800 548 808 1,011 1,139 1,243 1,329
3,900 559 826 1,033 1,164 1,270 1,359
4,000 571 844 1,056 1,190 1,298 1,388
4,100 580 862 1,078 1,215 1,326 1,418
4,200 592 880 1,101 1,240 1,353 1,448
4,300 603 898 1,123 1,266 1,381 1,477
4,400 615 916 1,146 1,291 1,409 1,507
4,500 626 933 1,161 1,316 1,435 1,535
4,600 636 949 1,181 1,338 1,459 1,561
4,700 647 964 1,200 1,360 1,483 1,586
4,800 657 980 1,220 1,381 1,507 1,612
4,900 667 995 1,239 1,403 1,531 1,637
5,000 676 1,010 1,257 1,424 1,554 1,661
5,100 686 1,025 1,275 1,444 1,576 1,685
5,200 695 1,039 1,294 1,465 1,599 1,709
5,300 705 1,054 1,312 1,486 1,621 1,733
5,400 714 1,069 1,330 1,506 1,644 1,757
5,500 724 1,083 1,348 1,527 1,666 1,781
5,600 733 1,098 1,367 1,548 1,689 1,805
5,700 743 1,113 1,385 1,568 1,712 1,829
5,800 753 1,127 1,403 1,589 1,734 1,853
5,900 762 1,142 1,421 1,610 1,757 1,877
6,000 772 1,157 1,440 1,630 1,779 1,901
6,100 781 1,171 1,458 1,651 1,802 1,926
6,200 791 1,186 1,476 1,672 1,824 1,950
6,300 800 1,198 1,498 1,690 1,844 1,970
6,400 808 1,209 1,511 1,705 1,860 1,988
6,500 816 1,219 1,524 1,720 1,876 2,005
6,600 823 1,230 1,538 1,735 1,893 2,023
6,700 830 1,240 1,551 1,750 1,909 2,040
6,800 837 1,251 1,564 1,764 1,925 2,058
6,900 844 1,261 1,577 1,779 1,942 2,075
7,000 851 1,272 1,591 1,794 1,958 2,093
7,100 858 1,282 1,604 1,809 1,975 2,110
7,200 865 1,293 1,617 1,824 1,991 2,127
7,300 872 1,303 1,630 1,839 2,007 2,145
7,400 879 1,313 1,644 1,854 2,024 2,162
7,500 885 1,324 1,657 1,869 2,040 2,179
7,600 891 1,333 1,668 1,881 2,053 2,194
7,700 896 1,342 1,679 1,893 2,066 2,208
7,800 901 1,350 1,691 1,905 2,079 2,223
7,900 907 1,359 1,702 1,917 2,093 2,238
8,000 912 1,368 1,713 1,929 2,106 2,252
8,100 917 1,377 1,724 1,941 2,119 2,267
8,200 922 1,386 1,736 1,953 2,133 2,281
8,300 928 1,395 1,747 1,965 2,146 2,296
8,400 933 1,404 1,758 1,977 2,159 2,311
8,500 938 1,413 1,769 1,989 2,173 2,325
8,600 944 1,421 1,780 2,002 2,186 2,340
8,700 949 1,430 1,792 2,014 2,199 2,354
8,800 954 1,437 1,800 2,024 2,210 2,366
8,900 958 1,444 1,809 2,033 2,220 2,376
9,000 962 1,450 1,817 2,042 2,230 2,387
9,100 966 1,457 1,825 2,052 2,241 2,398
9,200 971 1,463 1,833 2,061 2,251 2,408
9,300 975 1,470 1,842 2,070 2,261 2,419
9,400 979 1,476 1,850 2,079 2,271 2,430
9,500 983 1,483 1,858 2,089 2,281 2,440
9,600 988 1,489 1,866 2,098 2,291 2,451
9,700 992 1,496 1,874 2,107 2,301 2,461
9,800 996 1,502 1,883 2,117 2,311 2,472
9,900 1,000 1,508 1,891 2,126 2,321 2,483
10,000 1,005 1,515 1,899 2,165 2,331 2,493
10,400 1,022 1,541 1,932 2,202 2,372 2,536
10,500 1,027 1,548 1,940 2,212 2,382 2,546
10,600 1,032 1,554 1,948 2,221 2,392 2,557
10,700 1,036 1,561 1,956 2,230 2,402 2,567
10,800 1,040 1,567 1,965 2,240 2,412 2,578
10,900 1,044 1,573 1,973 2,249 2,422 2,589
11,000 1,049 1,580 1,981 2,258 2,432 2,599
11,100 1,053 1,587 1,989 2,268 2,443 2,610
11,200 1,058 1,593 1,997 2,277 2,453 2,620
11,300 1,062 1,600 2,005 2,286 2,463 2,631
11,400 1,066 1,606 2,013 2,295 2,473 2,642
11,500 1,070 1,613 2,021 2,305 2,483 2,652
11,600 1,075 1,619 2,029 2,314 2,493 2,663
11,700 1,079 1,626 2,037 2,323 2,503 2,673
11,800 1,084 1,633 2,046 2,333 2,513 2,684
11,900 1,088 1,639 2,054 2,342 2,523 2,695
12,000 1,093 1,646 2,062 2,351 2,533 2,705
12,100 1,097 1,653 2,070 2,361 2,544 2,716
12,200 1,102 1,659 2,078 2,370 2,554 2,726
12,300 1,106 1,666 2,086 2,379 2,564 2,737
12,400 1,110 1,672 2,094 2,388 2,574 2,748
12,500 1,114 1,679 2,102 2,398 2,584 2,758
12,600 1,119 1,685 2,110 2,407 2,594 2,769
12,700 1,123 1,692 2,118 2,416 2,604 2,779
12,800 1,128 1,699 2,127 2,426 2,614 2,790
12,900 1,132 1,705 2,135 2,435 2,624 2,801
13,000 1,137 1,712 2,143 2,444 2,634 2,811
13,100 1,141 1,719 2,151 2,454 2,645 2,822
13,200 1,146 1,725 2,159 2,463 2,665 2,832
13,300 1,150 1,732 2,167 2,472 2,665 2,843
13,400 1,154 1,738 2,175 2,481 2,675 2,854
13,500 1,158 1,745 2,183 2,491 2,685 2,864
13,600 1,163 1,751 2,191 2,500 2,695 2,875
13,700 1,167 1,758 2,199 2,509 2,705 2,885
13,800 1,172 1,765 2,208 2,519 2,715 2,896
13,900 1,176 1,771 2,216 2,528 2,725 2,907
14,000 1,181 1,778 2,224 2,537 2,735 2,917
14,100 1,185 1,785 2,232 2,547 2,746 2,928
14,200 1,190 1,791 2,240 2,556 2,756 2,938
14,300 1,194 1,798 2,248 2,565 2,766 2,949
14,400 1,198 1,804 2,256 2,574 2,776 2,960
14,500 1,202 1,811 2,264 2,584 2,786 2,970
14,600 1,207 1,817 2,272 2,593 2,796 2,981
14,700 1,211 1,824 2,280 2,602 2,806 2,991
14,800 1,216 1,831 2,289 2,612 2,816 3,002
14,900 1,220 1,837 2,297 2,621 2,826 3,013
15,000 1,225 1,844 2,305 2,630 2,836 3,023
FORM 3A
AOC-FC-3
Rev. 10-17 NW
EA L TH OF KE For Office Use Only

NT
O
Commonwealth of Kentucky

COMM

UCKY
lex

Court of Justice www.courts.ky.gov Case #: ______________________

et
justitia

CO

E
U
q Minor Children Involved

C
RT TI
OF JUS

q Protective Order Issued For: 000

County: ______________________
q Petitioner q Circuit q District q Family Court
Division: _____________________
q Respondent Case Data Information Sheet
PETITIONER: RESPONDENT:
Name: ______________________________________ Name: ______________________________________
Address: ____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
____________________________________________ ____________________________________________
Telephone: (include area code) ______________________ Telephone: (include area code) ______________________
Email: ______________________________________ Email: ______________________________________
DOB: _______________________________________ DOB: _______________________________________
SSN: _______________________________________ SSN: _______________________________________
Relationship to Respondent: _____________________ Relationship to Petitioner: _______________________
For ALL OTHER PARTIES to this case: please list below the name, current address, date of birth (DOB), social security
number (SSN), and relationship to the Petitioner, of any other parties to this action, or children of the Petitioner or Respondent.
If there is not enough room below, please attach a separate sheet with all the information requested.
OTHER PARTIES/CHILDREN:
Name: ______________________________________ Name: ______________________________________
Address: ____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
Telephone: (include area code) ______________________ Telephone: (include area code) ______________________
DOB: _______________________________________ DOB: _______________________________________
SSN: _______________________________________ SSN: _______________________________________
Relationship to Respondent: _____________________ Relationship to Petitioner: _______________________
Name: ______________________________________ Name: ______________________________________
Address: ____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
Telephone: (include area code) ______________________ Telephone: (include area code) ______________________
DOB: _______________________________________ DOB: _______________________________________
SSN: _______________________________________ SSN: _______________________________________
Relationship to Respondent: _____________________ Relationship to Petitioner: _______________________
Please list any/all cases, pending, or heard within the last five (5) years, that have involved the parties or children of the
parties in Family, District or Circuit Court. Please provide the case number, name of party and type of case:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

_____________________________________________
NOTICE TO FILING PARTY: A REDACTED
Signature of Preparer/Relationship to Petitioner
COPY MUST BE FILED PURSUANT TO CR 7.03.
This form shall be completed in full, pursuant Print Name: ___________________________________
to local rule and in compliance with federal law. Address: _____________________________________
_____________________________________________
Telephone: (include area code) _______________________
DISTRIBUTION: Cabinet for Health and Family Services, placing a copy in the County Attorney's Wage Withholding Order Box in
Circuit Clerk's Office
FORM 3B
AOC-FC-3
Rev. 10-17 NW
EA L TH OF KE For Office Use Only

NT
O
Commonwealth of Kentucky

COMM

UCKY
lex

Court of Justice www.courts.ky.gov Case #: ______________________

et
justitia

CO

E
U
q Minor Children Involved

C
RT TI
OF JUS

q Protective Order Issued For: 000

County: ______________________
q Petitioner q Circuit q District q Family Court
Division: _____________________
q Respondent Case Data Information Sheet
PETITIONER: RESPONDENT:
Name: ______________________________________ Name: ______________________________________
Address: ____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
____________________________________________ ____________________________________________
Telephone: (include area code) ______________________ Telephone: (include area code) ______________________
Email: ______________________________________ Email: ______________________________________
DOB: _______________________________________
XX/XX/XXXX DOB: _______________________________________
XX/XX/XXXX
SSN: _______________________________________
XXX-XX-XXXX SSN: _______________________________________
XXX-XX-XXXX
Relationship to Respondent: _____________________ Relationship to Petitioner: _______________________
For ALL OTHER PARTIES to this case: please list below the name, current address, date of birth (DOB), social security
number (SSN), and relationship to the Petitioner, of any other parties to this action, or children of the Petitioner or Respondent.
If there is not enough room below, please attach a separate sheet with all the information requested.
OTHER PARTIES/CHILDREN:
Name: ______________________________________ Name: ______________________________________
Address: ____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
Telephone: (include area code) ______________________ Telephone: (include area code) ______________________
DOB: _______________________________________
XX/XX/XXXX DOB: _______________________________________
XX/XX/XXXX
SSN: _______________________________________
XXX-XX-XXXX SSN: _______________________________________
XXX-XX-XXXX
Relationship to Respondent: _____________________ Relationship to Petitioner: _______________________
Name: ______________________________________ Name: ______________________________________
Address: ____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
Telephone: (include area code) ______________________ Telephone: (include area code) ______________________
DOB: _______________________________________
XX/XX/XXXX DOB: _______________________________________
XX/XX/XXXX
SSN: _______________________________________
XXX-XX-XXXX SSN: _______________________________________
XXX-XX-XXXX
Relationship to Respondent: _____________________ Relationship to Petitioner: _______________________
Please list any/all cases, pending, or heard within the last five (5) years, that have involved the parties or children of the
parties in Family, District or Circuit Court. Please provide the case number, name of party and type of case:
_______________________________________________________________________________________________
_______________________________________________________________________________________________

_____________________________________________
NOTICE TO FILING PARTY: A REDACTED
Signature of Preparer/Relationship to Petitioner
COPY MUST BE FILED PURSUANT TO CR 7.03.
This form shall be completed in full, pursuant Print Name: ___________________________________
to local rule and in compliance with federal law. Address: _____________________________________
_____________________________________________
Telephone: (include area code) _______________________
DISTRIBUTION: Cabinet for Health and Family Services, placing a copy in the County Attorney's Wage Withholding Order Box in
Circuit Clerk's Office
FORM 4A

COMMONWEALTH OF KENTUCKY
000
___________________ CIRCUIT COURT

CASE NO._________________________

IN RE THE MARRIAGE OF:

_______________________ PETITIONER
(Print name of Petitioner)

V PETITION FOR DISSOLUTION OF MARRIAGE

(With Children Under 18)

________________________ RESPONDENT
(Print name of Respondent)

Domestic Violence Order #_______________

*** *** ***

1. The parties are spouses having been lawfully married on __________________

(date of marriage)

in ____________________County, _____________________, where the marriage is registered.

(County) (State)

2. The Petitioner’s date of birth is ________________and is ____ years of age; he/she

(month/day/year) (Petitioners age)

resides at __________________________, ___________________, ________________,

(Petitioner’s street address) (Petitioner’s City) (Petitioner’s State)

__________ and □ has □ has not resided in this state continuously for a period of more than 180
(Petitioner’s Zip Code)

1
Rev. 11/2016 Pro Se Form- Appalachian Research & Defense Fund
FORM 4A

days prior to the filing of this petition, and has lived in the Commonwealth since ___________.

3. The Respondent’s date of birth is _____________and he/she is ____ years of age; he/she
(month/day/year) (Respondent’s age)

resides at __________________________, ___________________, ________________,

(Respondent’s street address) (Respondent’s City) (Respondent’s State)

__________ and □ has □ has not resided in this state continuously for a period of more than 180
(Respondent’s Zip Code)

days prior to the filing of this petition, and has lived in the Commonwealth since ___________.

4. The Petitioner’s social security number is _ _ _-_ _-_ _ _.

5. The Respondent’s social security number is _ _ _-_ _-_ _ _.

6. The parties are separated, having been separated since ____________________

(date of separation)

And having remained separated since that time.

7. The parties have ___ child(ren) together under the age 18. He/she/they is/are:

_______________________ _______________________
(Childs Full Name) (Childs date of birth and age)

_______________________ _______________________
(Childs Full Name) (Childs date of birth and age)

_______________________ _______________________
(Childs Full Name) (Childs date of birth and age)

_______________________ _______________________
(Childs Full Name) (Childs date of birth and age)

8. The Child(ren) currently live(s) with □ the Petitioner or □ the Respondent

at________________________________________________________.
2
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FORM 4A

(Address)

9. During the last five years, the child(ren) has/have lived at the following addresses:

a. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

b. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

c. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

d. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

e. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

10. The Petitioner

□ has not participated in, and does not know about, any other litigation in Kentucky or
elsewhere concerning custody of a child subject to these proceedings

OR

□ has participated in, or knows about, other litigation in Kentucky or elsewhere

concerning custody of a child subject to these proceedings (complete information below)

a. Names of child(ren) ___________________________________________

b. □ District Court □ Circuit □ Juvenile □ Family □ Other
c. Case Number ________________________________________________
d. County: __________________ State ______________________________
e. Brief description of order or judgment entered:
__________________________________________________________________

3
Rev. 11/2016 Pro Se Form- Appalachian Research & Defense Fund
FORM 4A

__________________________________________________________________
__________________________________________________________________
f. Type of proceeding and current status of case:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
11. CUSTODY
The □ Petitioner OR □ Respondent OR □both parties is/are the proper person(s) to have
□ joint custody OR □ sole custody of the minor child(ren) and this would be in the
child(ren)’s best interest(s).

12. VISITATION, CUSTODY AND CHILD SUPPORT

□ No arrangements have been made between the parties for visitation, custody and child
support.
OR
□ Arrangements have been made between the parties regarding the custody, support and
visitation for the minor child(ren).
13. The □ Petitioner OR □ Respondent should be ordered to pay child support.
14. □ The Petitioner is OR □ is not pregnant.
OR
□ To the best of my knowledge the Respondent □ is OR □ is not pregnant.
15. The marriage of the parties is irretrievably broken.

16. 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
4
Rev. 11/2016 Pro Se Form- Appalachian Research & Defense Fund
FORM 4A

property and/or debt.

ACCORDINGLY, the Petitioner, _______________________ demands as follows:
(Petitioner’s name)

A. Dissolution of the marriage;

B. Maintenance;
□ That neither party pay maintenance to the other.
OR
□ The Respondent pay maintenance to the Petitioner.
C. □ The Petitioner OR □ The Respondent be ordered to pay child support in accordance
with Kentucky Child Support Guidelines or different amount upon which the parties agree,

D. □ The Petitioner OR □ The Respondent OR □ both be granted □ sole custody OR □ joint

custody;.
E. The child(ren) to primarily live with □ the Petitioner OR □ the Respondent;
F. Reasonable visitation to the parties as we determine or as determined by the Court;
G. The equitable division of marital property and/or debt, if any, and the restoration of
non-marital property to the appropriate party.
H. Any and all other relief to which Petitioner may appear entitled.
I. □ The Petitioner be restored to her former name, ____________________.

I, ___________________________ have read, or had read to me, the above statements contained
(Petitioner’s name)

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

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

5
Rev. 11/2016 Pro Se Form- Appalachian Research & Defense Fund
FORM 4A

COMMONWEALTH OF KENTUCKY
COUNTY OF _________________
Subscribed and sworn to before me by the above-named Petitioner on this ______

day of ______________, 2_____.

My commission expires: ______________.

__________________________
NOTARY PUBLIC
STATE AT LARGE, KENTUCKY

6
Rev. 11/2016 Pro Se Form- Appalachian Research & Defense Fund
FORM 4B- REDACTED COPY

COMMONWEALTH OF KENTUCKY

000
___________________ CIRCUIT COURT

CASE NO._________________________

IN RE THE MARRIAGE OF:

_______________________ PETITIONER
(Print name of Petitioner)

V PETITION FOR DISSOLUTION OF MARRIAGE

(With Children Under 18)

________________________ RESPONDENT
(Print name of Respondent)

Domestic Violence Order #_______________

*** *** ***

1. The parties are spouses having been lawfully married on __________________

(date of marriage)

in ____________________County, _____________________, where the marriage is registered.

(County) (State)

2. The Petitioner’s date of birth is XX/XX/II and is XX years of age; he/she

resides at __________________________, ___________________, ________________,

(Petitioner’s street address) (Petitioner’s City) (Petitioner’s State)

__________ and □ has □ has not resided in this state continuously for a period of more than 180
(Petitioner’s Zip Code)

days prior to the filing of this petition, and has lived in the Commonwealth since ___________.

3. The Respondent’s date of birth is XX/XX/II and he/she is XX years of age; he/she
1
Rev. 11/2016 *REDACTED COPY* Pro Se Form- Appalachian Research and Defense Fund
FORM 4B- REDACTED COPY

resides at __________________________, ___________________, ________________,

(Respondent’s street address) (Respondent’s City) (Respondent’s State)

__________ and □ has □ has not resided in this state continuously for a period of more than 180
(Respondent’s Zip Code)

days prior to the filing of this petition, and has lived in the Commonwealth since ___________.

4. The Petitioner’s social security number is XXX-XX-XXXX

5. The Respondent’s social security number is XXX-XX-XXXX

6. The parties are separated, having been separated since ____________________

(date of separation)

And having remained separated since that time.

7. The parties have ___ child(ren) together under the age 18. He/she/they is/are:

_______________________ XX/XX/II
_______________________
( Initials of child ) (Childs date of birth and age)
(Redacted format is xx/xx/11)

_______________________ XX/XX/II
_______________________
( Initials of child ) (Childs date of birth and age)
(Redacted format is xx/xx/11)

_______________________ _______________________
XX/XX/II
( Initials of child ) (Childs date of birth and age)
(Redacted format is xx/xx/11)

_______________________ _______________________
XX/XX/II
( Initials of child ) (Childs date of birth and age)
(Redacted format is xx/xx/11)

8. The Child(ren) currently live(s) with □ the Petitioner or □ the Respondent

at________________________________________________________.
(Address)

9. During the last five years, the child(ren) has/have lived at the following addresses:

a. ____________________________________________________________
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FORM 4B- REDACTED COPY

with □ the Petitioner □ the Respondent □both

b. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

c. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

d. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

e. ____________________________________________________________
with □ the Petitioner □ the Respondent □both

10. The Petitioner

□ has not participated in, and does not know about, any other litigation in Kentucky or
elsewhere concerning custody of a child subject to these proceedings

OR

□ has participated in, or knows about, other litigation in Kentucky or elsewhere

concerning custody of a child subject to these proceedings (complete information below)

a. Names of child(ren) ___________________________________________

b. □ District Court □ Circuit □ Juvenile □ Family □ Other
c. Case Number ________________________________________________
d. County: __________________ State ______________________________
e. Brief description of order or judgment entered:
__________________________________________________________________
__________________________________________________________________
Type of proceeding and current status of case:
_________________________________________________________________________
_________________________________________________________________________
11. CUSTODY
The □ Petitioner OR □ Respondent OR □both parties is/are the proper person(s) to have

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FORM 4B- REDACTED COPY

□ joint custody OR □ sole custody of the minor child(ren) and this would be in the
child(ren)’s best interest(s).

12. VISITATION, CUSTODY AND CHILD SUPPORT

□ No arrangements have been made between the parties for visitation, custody and child
support.
OR
□ Arrangements have been made between the parties regarding the custody, support and
visitation for the minor child(ren).
13. The □ Petitioner OR □ Respondent should be ordered to pay child support.
14. □ The Petitioner is OR □ is not pregnant.
OR
□ To the best of my knowledge the Respondent □ is OR □ is not pregnant.
15. The marriage of the parties is irretrievably broken.

16. 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)

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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FORM 4B- REDACTED COPY

C. □ The Petitioner OR □ The Respondent be ordered to pay child support in accordance

with Kentucky Child Support Guidelines or different amount upon which the parties agree,
D. □ The Petitioner OR □ The Respondent OR □ both be granted □ sole custody OR □ joint
custody;.
E. The child(ren) to primarily live with □ the Petitioner OR □ the Respondent;
F. Reasonable visitation to the parties as we determine or as determined by the Court;
G. The equitable division of marital property and/or debt, if any, and the restoration of
non-marital property to the appropriate party.
H. Any and all other relief to which Petitioner may appear entitled.
I. □ The Petitioner be restored to her former name, ____________________.

I, ___________________________ have read, or had read to me, the above statements contained
(Petitioner’s name)
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

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

COMMONWEALTH OF KENTUCKY
COUNTY OF _________________
Subscribed and sworn to before me by the above-named Petitioner on this ______

day of ______________, 2_____.

My commission expires: ______________. __________________________

NOTARY PUBLIC
STATE AT LARGE, KENTUCKY

5
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FORM 5
q AOC-238.1 Doc. Code DSPV NW
EA L TH OF KE

q AOC-239.1 Doc. Code DSFV Case No. ____________________

NT
O
COMM

UCKY
lex
et

Rev. 1-15 Court ____________________

justitia

CO

E
U

C
RT TI

Page 1 of 5 OF JUS

000
County ____________________
Commonwealth of Kentucky SIMPLIFIED
Court of Justice www.courts.ky.gov q PRELIMINARY q FINAL VERIFIED Division ____________________
FCRPP 2 and FCRPP 3 DISCLOSURE STATEMENT*
*FOR PARTIES WITH COMBINED INCOME LESS THAN $100,000 AND COMBINED ASSETS LESS THAN $100,000

IN RE THE MARRIAGE OF:

________________________________________ PETITIONER

and

________________________________________ RESPONDENT

q Petitioner q Respondent submits under oath the following Verified Disclosure Statement pursuant to FCRPP 2 OR
FCRPP 3, which requires full and prompt disclosure of the following information:

NOTE: A response of “see attached” is not appropriate for any portion of this statement. Attach documents
requested herein only.

I. IDENTIFYING INFORMATION OF BOTH PARTIES

Petitioner Respondent

Name: _______________________________________ Name: ______________________________________

Street Address: ________________________________ Street Address: _______________________________

City, State, Zip: ________________________________ City, State, Zip: _______________________________

Age: ____ Phone #: _________________________ Age: ____ Phone #: ___________________________

II. INCOME AND EMPLOYMENT INFORMATION OF BOTH PARTIES (If self-employed name of company and
adjusted gross monthly income)

Petitioner Respondent

Employer Name: _______________________________ Employer Name: ______________________________

Gross monthly income: $ ________________________ Gross monthly income: $ ________________________

Other income: $ _______________________________ Other income: $ _______________________________

III. MARRIAGE INFORMATION

Date of Marriage: ______________________________ Date of separation: _____________________________

Place of Marriage (city, county & state): _______________________________________________________________

FORM 5
q AOC-238.1 Doc. Code DSPV q AOC-239.1 Doc. Code DSFV
Rev. 1-15 Disclosure of _____________________________________
Page 2 of 5 Case No. _________________________________________

IV. CHILDREN’S INFORMATION (If more than 3 children, continue on a separate sheet)
A. Minor children born to parties (number ________) q More CHILDREN attached?
Name Current Age

B. Monthly child care/day care expenses: Cost $ ________________ Paid by ________________

C. Monthly medical, dental and vision insurance for children: Cost $ ________________ Paid by ________________
D. Either party court-ordered to pay child support for a child born before the children born of this marriage? q Yes q No
Paying party _____________________________________________ Amount: $ ____________________________
Children: (List names and ages) _____________________________________________________________________
_______________________________________________________________________________________________

V. SUMMARY OF ASSETS & DEBTS

Do you own any real estate? Yes _____ No ____ If yes, put information below.
Do you own any vehicles? Yes _____ No ____ If yes, put information below.
Do you have any bank accounts or savings? Yes _____ No ____ If yes, put information below.
Do you have assets in a safety deposit box? Yes _____ No ____ If yes, put information below.
Do you have any stocks, bonds, etc.? Yes _____ No ____ If yes, put information below.
Do you have any retirement account, IRA, 401k? Yes _____ No ____ If yes, put information below.
Do you have any cash value in life insurance? Yes _____ No ____ If yes, put information below.
Do you own any interest in a business? Yes _____ No ____ If yes, put information below.
Are there any other assets? Yes _____ No ____ If yes, put information below.
Are there assets held for another person, including children Yes _____ No ____ If yes, put information below.
Have you and your spouse already divided your household goods and personal property? Yes _____ No ____

Item 1:
Item Description: _________________________________________________________________________________
Who Holds Possession? ____________________________ Valuation Date: ________________________________
Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________
Is this a leased vehicle/asset? q Yes q No If yes, please complete the following: Monthly Payment: _______________
Lease Term Ends: ________________
Item 2:
Item Description: _________________________________________________________________________________
Who Holds Possession? ____________________________ Valuation Date: ________________________________
Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________
Is this a leased vehicle/asset? q Yes q No If yes, please complete the following: Monthly Payment: _______________
Lease Term Ends: ________________
Item 3:
Item Description: _________________________________________________________________________________
Who Holds Possession? ____________________________ Valuation Date: ________________________________
Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________
Is this a leased vehicle/asset? q Yes q No If yes, please complete the following: Monthly Payment: _______________
Lease Term Ends: ________________
FORM 5
q AOC-238.1 Doc. Code DSPV q AOC-239.1 Doc. Code DSFV
Rev. 1-15 Disclosure of _____________________________________
Page 3 of 5 Case No. _________________________________________

Item 4:
Item Description: _________________________________________________________________________________
Who Holds Possession? ____________________________ Valuation Date: ________________________________
Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________
Is this a leased vehicle/asset? q Yes q No If yes, please complete the following: Monthly Payment: _______________
Lease Term Ends: ________________

Item 5:
Item Description: _________________________________________________________________________________
Who Holds Possession? ____________________________ Valuation Date: ________________________________
Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________
Is this a leased vehicle/asset? q Yes q No If yes, please complete the following: Monthly Payment: _______________
Lease Term Ends: ________________

More OTHER ASSETS attached? q Yes q No Total Values: ____________________

Do you owe any debts? q Yes q No If yes, put information below.

Creditor 1:
Creditor: ________________________________________________________________________________________
Party Named on Debt: _____________________________________________ Premarital Account? _____________
Valuation Date: ____________________ Monthly Payment: ________________ Total Balance: _________________

Creditor 2:
Creditor: ________________________________________________________________________________________
Party Named on Debt: _____________________________________________ Premarital Account? _____________
Valuation Date: ____________________ Monthly Payment: ________________ Total Balance: _________________

Creditor 3:
Creditor: ________________________________________________________________________________________
Party Named on Debt: _____________________________________________ Premarital Account? _____________
Valuation Date: ____________________ Monthly Payment: ________________ Total Balance: _________________

Creditor 4:
Creditor: ________________________________________________________________________________________
Party Named on Debt: _____________________________________________ Premarital Account? _____________
Valuation Date: ____________________ Monthly Payment: ________________ Total Balance: _________________

Creditor 5:
Creditor: ________________________________________________________________________________________
Party Named on Debt: _____________________________________________ Premarital Account? _____________
Valuation Date: ____________________ Monthly Payment: ________________ Total Balance: _________________

More DEBTS attached? q Yes q No Total Debt Balances: __________________

FORM 5
q AOC-238.1 Doc. Code DSPV q AOC-239.1 Doc. Code DSFV
Rev. 1-15 Disclosure of _____________________________________
Page 4 of 5 Case No. _________________________________________

Are you claiming a right to maintenance? q Yes q No If yes, complete this expense list:
A. COMMON EXPENSES FOR FAMILY B. YOUR PERSONAL EXPENSES
(Party and any children of the marriage) (not including any children’s expenses)

FOOD/GROCERIES FOR FAMILY Church and charitable donations

(Non-entertainment) Clothing

HOUSING Cosmetics, hygiene & toiletries

Cable Disability insurance

Garbage collection Dry cleaning & laundry

Electric, gas, propane & oil utilities Entertainment, including

restaurants & movies
Home maintenance & repairs Hair care (barber, salon, etc.)
Homeowner’s insurance Internet access
Household supplies Life insurance (whole life or term)
Maid service Manicures & pedicures
Property taxes Newspapers, magazines & books
Rent or 1st mortgage Professional dues or uniforms
2nd mortgage/home equity loan Sports, exercise, hobbies, crafts, etc.
Telephone Travel (monthly average)
Mobile phone MEDICAL
Vet/pet supplies Dental (including orthodontics)
Yard expense/maintenance Eyeglasses, contacts & hearing aids,
exams and testing
Water/sewage

TRANSPORTATION Insurance (hospitalization)

Gas and oil Medical doctor(s)

Liability insurance Prescription medication
License/taxes/tag OTHER PERSONAL EXPENSES (list):
Payment/loan

Repairs/maintenance

Other – bus, taxi, tolls & parking Sub-total from attached other personal
expenses, if needed q Attached
OTHER FAMILY EXPENSES (list):
SUBTOTAL FROM COLUMN B
SUBTOTAL FROM COLUMN A

Sub-total from attached other family SUBTOTAL FROM CHILDREN’S

expenses, if needed q Attached EXPENSE LIST ATTACHMENT

SUBTOTAL (Column A) GRAND TOTAL

of column a, b, and
attachments
FORM 5
q AOC-238.1 Doc. Code DSPV q AOC-239.1 Doc. Code DSFV
Rev. 1-15 Disclosure of _____________________________________
Page 5 of 5 Case No. _________________________________________

VERIFICATION

I, ________________________________________, declare under penalty of perjury that the information

contained herein, including the information provided on any schedules and attachments, is true and accurate to the best
of my knowledge, information and belief. Further, I acknowledge that I have read the foregoing instructions and have
followed those instructions to the best of my ability.
____________________________________________
q Petitioner q Respondent {check one}

STATE OF ____________________________ )
) SS
COUNTY OF ____________________________ )

Subscribed and sworn before me by ____________________________, this _____ day of _________________,

________.
My commission expires: ______________________

______________________________________
NOTARY PUBLIC/TITLE
CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a copy of this Verified Disclosure Statement (with schedules and attachments) was
served by q mail, postage prepaid, or q hand-delivery, or q electronic means, in accordance with Kentucky Rule of Civil
Procedure (CR) 5.02, on (name) _____________________________________________________________________
at (address) _____________________________________________________________________________________,
this the _______ day of ________________________, _________.

____________________________________________
Signature

q Attorney for Petitioner q Attorney for Respondent

✔ Petitioner q Respondent
q

Address:
____________________________________________
____________________________________________
____________________________________________
Phone: ( ) ________________________________
Fax: ( ) _________________________________
Email: _____________________________________

*NOTE
When this form is utilized as an AOC-238.1, Simplified Preliminary Verified Disclosure Statement, unless otherwise
ordered by the Court or required by Local Rule, this form is NOT to be filed with the Court. FCRPP 2(3). However, the
entire form and all attachments are to be exchanged between the parties within 45 days of service of the petition on the
respondent, and objections thereto shall be exchanged within 20 days thereafter.
When this form is utilized as an AOC-239.1, Simplified Final Verified Disclosure Statement, pursuant to FCRPP 3(3),
this form is to be filed with the Court no later than 5 days prior to the trial if property matters are in dispute at that trial.
However, the parties may file an Affidavit of No Change In Circumstances, AOC- 239.2, if the AOC-238.1, Simplified
Preliminary Verified Disclosure Statement was filed with the Court. A copy of the Final Verified Disclosure Statement
or the Affidavit, together with any supporting documentation, shall be provided to the opposing party 15 days prior to
trial unless otherwise ordered by the Court.
FORM 6

COMMONWEALTH OF KENTUCKY
000
___________________ CIRCUIT COURT

CASE NO._________________________

IN RE THE MARRIAGE OF:

_______________________ PETITIONER
(Print name of Petitioner)

V ENTRY OF APPEARANCE AND WAIVER

________________________ RESPONDENT
(Print name of 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 any right of appeal.
____________________________
(Signature of Respondent)

COMMONWEALTH OF KENTUCKY
COUNTY OF _________________
Subscribed and sworn to before me by the above-named Respondent on this ______

day of ______________, 2_____.

My commission expires: ______________.

__________________________
NOTARY PUBLIC
STATE-AT-LARGE, KENTUCKY

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FORM 7

COMMONWEALTH OF KENTUCKY
000
___________________ CIRCUIT COURT

CASE NO._________________________

IN RE THE MARRIAGE OF:

_______________________ PETITIONER
(Print name of Petitioner)

V MARITAL SETTLEMENT AGREEMENT

(with Children Under 18 and/or still in High School)

________________________ RESPONDENT
(Print name of Respondent)

*** *** ***

The parties agree to the following:

I. The parties are spouses. 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 following minor child/children was/were born of the marriage:

Name(s) Date(s) of Birth

__________________________ ______________________
__________________________ ______________________
__________________________ ______________________
__________________________ ______________________

IV. The parties wish to settle the issues of custody, child support, visitation, maintenance,

division of property, and assignment of debts.

V. CUSTODY

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FORM 7

□ The parties shall have joint custody of the child(ren). Major decisions affecting the
welfare of the child(ren) will be made jointly by the parties.
OR
The □ petitioner □ respondent shall have sole custody of the child(ren).
VI. PARENTING TIME
The child(ren) shall live primarily with □ Petitioner or □ Respondent and the other
parent shall be entitled to visitation at such times and places as the parties shall agree
OR at the following times:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
OR
□ The children shall share time equally between the parties as agreed or as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

VII. Both parents shall be entitled to attend school, church, sports, or other activities in
which the child/children is/are engaged, subject to the restrictions of any protective
order.
VIII. Each party shall keep the other reasonably apprised as to where the child(ren) shall be
and shall provide a phone number where the child(ren) can be reached.
IX. Each party shall notify the other of any illness or emergency that may arise affecting
the child(ren).
X. Neither party shall use illegal drugs or use alcohol to excess in the presence of the
child(ren).
XI. CHILD SUPPORT
The □ Petitioner □ Respondent shall pay $_________ □ per week □ every two weeks
(amount)

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FORM 7

□ twice a month □ monthly as child support, payable by wage assignment order. This
amount is based on the Kentucky Child Support Guidelines (attach worksheet).
OR
□ The amount of child support deviates from the guideline amount because
___________________________________________________________

OR
□ The amount of child support has already been established pursuant to case
#__________________. The □ Petitioner □ Respondent will pay in accordance with
this judgment.
OR
□ Based on the financial condition of the parties, no child support is to be paid at this
time.
XII. HEALTH INSURANCE
□ The child(ren) are covered by a government insurance plan, such as KCHIP, Passport
or Medicaid. Either party will obtain health insurance for the child(ren) as soon as it is
available at a reasonable cost.
OR
The □ Petitioner □ Respondent shall maintain health insurance on the child(ren),
provided it is available at reasonable cost. The party providing coverage will convey to
the other party an insurance card showing coverage. In addition, the Petitioner shall pay
___________% and the Respondent shall pay _________% of the extraordinary medical
expenses. “Extraordinary medical expenses” means uninsured expenses in excess of
$100.00 per child per calendar year. “Extraordinary medical expenses” includes, but is
not limited to the costs that are reasonably necessary for medical, surgical, dental,
orthodontia, optometric, nursing, and hospital services; for professional counseling or
psychiatric therapy for diagnosed medical disorders; and for drugs and medical supplies,
appliances, laboratory, diagnostic, and therapeutic services.

XIII. DEPENDENT EXEMPTION

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FORM 7

The □ Petitioner □ Respondent shall be entitled to claim the child(ren) as a

dependent/as dependents for tax purposes.
OR
□ The parties shall share entitlement to claim the child(ren) as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

XIV. NON-MARITAL PROPERTY

□ There is no non-marital property that has not already been restored to the party to
whom it belongs.
OR
The Petitioner shall keep his/her non-marital property listed below:
_____________________________________________________________________
_____________________________________________________________________
The Respondent shall keep his/her non-marital property listed below:
_____________________________________________________________________
_____________________________________________________________________

XV. MARITAL PROPERTY

A. Real Estate
□ The parties own no marital real estate
OR
□ The parties have agreed to sell the real estate located at net proceeds of
__________________________________________________________,
( address, including city and state)
and the parties will split the net proceeds of the sale with Petitioner receiving
_________% and Respondent receiving ________%.
OR

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FORM 7

□ The □ Petitioner □ Respondent is awarded the real estate located at

_____________________________________________________________.
( address, including city and state)

The party who is keeping the property will 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 □ $_____
(amount of money)
within _____ 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.
B. Vehicles
The Petitioner is awarded □ no vehicle or □ the following vehicles(s):
________________________________________________________.
The Respondent is awarded □ no vehicle or □ the followings vehicles(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 he/she is awarded within _____ days.
C. 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: ____________________
______________________________________________________________.
( *identify accounts by bank and type of account-do not use account numbers)

□ The Respondent is awarded the following accounts: ____________________

______________________________________________________________.
( *identify accounts by bank and type of account-do not use account numbers)

D. Personal Property/Household Goods

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FORM 7

□ 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. Retirement
□ Neither party has any retirement funds.
□ Each party shall keep his or her own retirement funds.
F. Other Marital Property
□ The Petitioner is awarded: _________________________________________
_________________________________________________________________
□ The Respondent is awarded: ________________________________________
_________________________________________________________________
_________________________________________________________________

XVI. DEBTS
□ The are no marital debts.
OR
□ 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:
_____________________________________________________________________
_____________________________________________________________________
EQUITABLE DIVISION OF PROPERTY
□ The parties agree that the division of property and debts is equitable.
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FORM 7

OR
□ In order to make the division of property and debts equitable, □ Petitioner or □
Respondent shall pay the other party $_______ within ______ days of the agreement.
(amount)

XVII. MAINTENANCE
□ 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
(ending date)
maintenance, or the cohabitation of the party with a non-related adult, whichever
occurs first.

In signing below, the parties acknowledge that this is a fair agreement, that they understand its
provisions, understand that it is legally binding document, and are entering the agreement freely.

________________________________ ___________________________________
(Signature of Petitioner) (Signature of Respondent)

Subscribed and sworn to before me by the above-named Petitioner on this ____ day of
____________, 20___.
My commission expires: __________________.
________________________________
NOTARY PUBLIC
STATE-AT-LARGE, KENTUCKY

Subscribed and sworn to before me by the above-named Respondent on this ____ day of
____________, 20___.
My commission expires: __________________.
________________________________
NOTARY PUBLIC
STATE-AT-LARGE, KENTUCKY

7
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 STOP

Have you filed forms 1-7 at the

courthouse?
You must wait at least one day before
you can sign and file forms 8-11.
FORM 8A
AOC- 239.2 Doc. Code: ANCC NW
EA L TH OF KE

Rev. 1-15 Case No. ____________________

NT
O
COMM

UCKY
lex

Page 1 of 2 et

Court ____________________
justitia

CO

E
U

C
RT TI
OF JUS
Commonwealth of Kentucky 000
County ____________________
Court of Justice www.courts.ky.gov Affidavit of No Change in Circumstances
Requiring the Filing of a Final Verified Division ____________________
FCRPP 3
Disclosure Statement
IN RE THE MARRIAGE OF:

________________________________________ PETITIONER

and

________________________________________ RESPONDENT

q Petitioner q Respondent submits under oath the following Affidavit pursuant to FCRPP 3, which requires full and
prompt disclosure of the following information:

1. That the Preliminary Verified Disclosure Statement was filed pursuant to Court Order or Local Rule on
_______________________________, _________.

2. That there are no changes in circumstance of the q Petitioner q Respondent since the date the Preliminary
Verified Disclosure Statement was filed; and, therefore no Final Verified Disclosure Statement is required to be
filed pursuant to FCRPP 3(3).

3. I understand that making a false statement in this Affidavit may subject me to the penalties for perjury as
contained in KRS Chapter 523. The maximum sentence for perjury is five (5) years imprisonment. In addition, it
may be grounds to set aside any judgment entered in this case.

4. I declare under the penalty of perjury that I have read or have had read to me the information contained on this
form and that the statements provided here are true, complete and accurate to the best of my personal knowledge.

_________________________________ ________________________________________
Date Affiant’s Signature

________________________________________
Affiant’s Name (Print or Type)

STATE OF ____________________________ )
) SS
COUNTY OF ____________________________ )

SUBSCRIBED AND SWORN TO before me this ________ day of ___________________________, _________.

My Commission Expires: ___________________ ________________________________________

NOTARY PUBLIC/TITLE
FORM 8A
AOC-239.2
Rev. 1-15 Case No. _________________________________
Page 2 of 2

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a copy of this Affidavit of No Change in Circumstances was served by q mail, postage
prepaid, or q hand-delivery, or q electronic means, in accordance with Kentucky Rule of Civil Procedure (CR) 5.02, on
(name) _______________________________________________________________________________________ at
(address) _______________________________________________________________________________________,
this the _______ day of ________________________, _________.

____________________________________________
Signature

q Attorney for Petitioner q Attorney for Respondent

q Petitioner q Respondent

Address:
____________________________________________
____________________________________________
____________________________________________
Phone: ( ) ________________________________
Fax: ( ) _________________________________
Email: _____________________________________
FORM 8B
q AOC-238.3 Doc. Code: ACKPDS
EA L TH OF KE
q AOC-239.3 Doc. Code: ACKFDS
NW
Case No. ____________________

NT
O
COMM

UCKY
lex

Rev. 1-15 et
justitia
Court ____________________

CO
Page 1 of 2

E
U

C
RT TI
OF JUS

County ____________________
000
Commonwealth of Kentucky ACKNOWLEDGMENT OF
Court of Justice www.courts.ky.gov q PRELIMINARY q FINAL VERIFIED Division ____________________
FCRPP 2 and FCRPP 3 DISCLOSURE STATEMENT*

IN RE THE MARRIAGE OF:

________________________________________ PETITIONER

and

________________________________________ RESPONDENT

All sections must be completed. If an amount is unknown, write “unknown”, if the question is inapplicable, write “N/A”.
If a question requires further documentation or an additional schedule, please attach. If maintenance is an issue or
there are property distribution issues, please proceed to use the full Mandatory Case Disclosure Form.

I, ________________________________________, declare under oath that my personal information is:

Name: ______________________________________________________
Address: ____________________________________________________
____________________________________________________
____________________________________________________
Age/Place birth: _______________________________________________
Date/Place marriage: __________________________________________
Spouse’s name: ______________________________________________
Spouse’s age: ________________________________________________
I am currently employed at: ______________________________________
cgfbasdfgb
I earn _________________ per ________________ (weekly, monthly, etc.)
****** My total gross monthly income (from all sources) is _______________

OTHER LEGAL ACTIONS

Please give the style, the case number, and the name of the Court or administrative agency for any case you are
a party in or have been within the last year as well as a brief description of the nature of the case and present status.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

REQUIRED ATTACHMENTS
“A” = to indicate that the requested document/information is attached
“U” = to indicate that the requested document/information is unavailable
(Provide explanation on a separate page)
“N/A” = if not applicable

I have provided a copy of the following documents to opposing party or opposing counsel:
____ 1. My three (3) most recent pay stubs
____ 2. A full and complete copy of my last Federal Tax Return
____ 3. First page of my last State Tax Return
FORM 8B
q AOC-238.3 Doc. Code q AOC 239.3 Doc. Code
Rev- 1-15 Disclosure of _____________________________________
Page 2 of 2 Case No. _________________________________________

I hereby acknowledge that the information contained in _____________________________’s Verified Disclosure

Statement is a true and accurate reflection of the financial disputes in this matter and that there are no additional assets, debts
or issues which require disclosure to the best of my knowledge and belief. Further, I hereby certify that the foregoing information
is true to the best of my knowledge, information and belief.

____________________________________________
q Petitioner
✔ q Respondent {check one}

STATE OF ____________________________ )
) SS
COUNTY OF ____________________________ )

Subscribed and sworn before me by ____________________________, this _____ day of _________________,

________.

My commission expires: ______________________

______________________________________
NOTARY PUBLIC/TITLE

CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of this Acknowledgment Of Verified Disclosure Statement (with schedules
and attachments) was served by q mail, postage prepaid, or q hand-delivery, or q electronic means, in accordance with
Kentucky Rule of Civil Procedure (CR) 5.02, on (name) ___________________________________________________
at (address) _____________________________________________________________________________________,
this the _______ day of ________________________, _________.

____________________________________________
Signature

q Attorney for Petitioner q Attorney for Respondent

q Petitioner q Respondent

Address:
____________________________________________
____________________________________________
____________________________________________
Phone: ( ) ________________________________
Fax: ( ) _________________________________
Email: _____________________________________

*NOTE
When this form is utilized in lieu of the AOC-238, Preliminary Verified Disclosure Statement, unless otherwise
ordered by the Court or required by Local Rule, this form is NOT to be filed with the Court. FCRPP 2(3). However,
the entire form and all attachments are to be exchanged between the parties within 45 days of service of the
petition on the respondent, and objections thereto shall be exchanged within 20 days thereafter.

When this form is utilized in lieu of the AOC-239, Final Verified Disclosure Statement, or AOC-239.2, Affidavit
of No Change in Circumstances, pursuant to FCRPP 3(3), this form is to be filed with the Court no later than 5
days prior to the trial if property matters are in dispute at that trial. A copy of this Acknowledgment shall also be
provided to the opposing party 15 days prior to trial unless otherwise ordered by the Court.
FORM 9

COMMONWEALTH OF KENTUCKY
000
_______________________ CIRCUIT COURT

CASE NO. _________________

IN RE: THE MARRIAGE OF:

________________________ PETITIONER
(print name of Petitioner)

v. DEPOSITION OF PETITIONER

________________________ RESPONDENT
(print name of 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 spouses status is: □ unemployed □ disabled □ retired □ employed as

_____________________________.
(type of occupation)

VII. We were married on ______________________ in ____________________ County,

(date of marriage) (county)
_________________.
(state)

VIII. We separated on ________________________ and have not live together as

(date of separation)
husband/wife since then.
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FORM 9

IX. □ We have no minor children of our marriage.

OR
□ We have the following minor child(ren) or our marriage:

Initials Age
____________ ___________

____________ ___________

____________ ___________

X. □ I am not □ my wife is not pregnant.

XI. Our marriage s 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. I am the Petitioner/Respondent (circle one). I □ want □ do not want my former name of
________________
(former name)

to be restored.

NOTE: If the parties have minor children of this marriage, this form may not be signed until 60
days have passed “from the date of service of the summons, the appointment of a warning order
attorney or the filing of an entry of appearance or a responsive pleading by the defendant,
whichever occurs first.” Kentucky Revised Statute 403.044
____________________________________
(Signature of Petitioner)

____________________________________
(Print Name of Petitioner)

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FORM 9

____________________________________
(Address)
____________________________________

____________________________________

____________________________________
(Telephone)

COMMONWEALTH OF KENTUCKY

COUNTY OF _____________________________

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

______________________, 20____.

NOTARY PUBLIC MY COMMISSION EXPIRES

STATE-AT-LARGE, KENTUCKY

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FORM 10

COMMONWEALTH OF KENTUCKY

_______________________
000 CIRCUIT COURT

CASE NO. _________________

IN RE: THE MARRIAGE OF

________________________ PETITIONER
(print name of Petitioner)

V.
FINDING OF FACTS AND
DECREE OF DISSOLUTION OF MARRIAGE
(With Children Under 18, With Agreement)

________________________ RESPONDENT
(print name of 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 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 that 60 days and more than 60 days have
elapsed since the Respondent was served with the Petition for Dissolution of Marriage or signed

the Entry of Appearance and Waiver or Marital Settlement Agreement.

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

403.170 do not apply.
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FORM 10

5. □ The following child/children was/were born of the marriage and is/are still

minor/minors:

Initial(s) Age
____________ ___________

____________ ___________

____________ ___________

6. The Petitioner Respondent 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, its

provisions with respect to custody and visitation to be in the child’s/children’s best interests, and

□ child support to be calculated in conformity with the statutory guidelines OR □ a deviation

from the child support guidelines to be justified because:

______________________________________________________________________________

OR □ a child support order has already been established.

On the basis of these findings,

IN IT HEREBY ORDERED AND ADJUDGED THAT:

1. The marriage between the Petitioner ___________________________, and the

(Name of Petitioner)

Respondent, _______________________________, of __________________________ is

(Name of Respondent) (Date of Marriage)
dissolved.

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

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FORM 10

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

3. □ The Petitioner/Respondent is restored to her former name, ______________.

(wife’s former name)
OR

□ Neither party seeks restoration to a former name.

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

____________________________________
JUDGE
____________________
000 CIRCUIT COURT

DATE: _____________________________

Tendered By:

**__________________________________
Signature of person filing
Finding of Fact and Decree

____________________________________
Printed name of person filing
Finding of Fact and Decree
____________________________________
(Address)
____________________________________

____________________________________

____________________________________
(Telephone)

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

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FORM 10

COMMONWEALTH OF KENTUCKY

COUNTY OF _____________________________

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

______________________, 20____.

NOTARY PUBLIC MY COMMISSION EXPIRES

STATE-AT-LARGE, KENTUCKY
CERTIFICATION

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

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

____________________________________
(Name of Other Party)
___________________________________
(Street Number and Name)
____________________________________
(City, State, Zip)
____________________________________
(Telephone)

I have filed this Finding of Fact and Decree with the Clerk of the _____________ Circuit

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

________________________________________________
(Signature) (Date)

Distribution List:

_____ Petitioner

_____ Respondent

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FORM 11

COMMONWEALTH OF KENTUCKY
000
_______________________ CIRCUIT COURT

CASE NO. _________________

IN RE THE MARRIAGE OF:

________________________ PETITIONER
(print name of Petitioner)

v. MOTION FOR FINAL DECREE

(With Agreement – Uncontested)

________________________ RESPONDENT
(print name of Respondent)
*** *** ***
NOTICE

Please take notice that the following motion shall be made on ___________________ at
(month, day, year)
_______ a.m./p.m. (circle one) in the above listed Court.
(time)

MOTION TO ENTER DECREE OF DISSOLUTION OF MARRIAGE

Comes now the Petitioner, pro se, and moves the Court to take this case under submission

and enter the final decree filed herewith. In support thereof, Petitioner states as follows:

1. The parties were married on ______________________. The parties were separated

on or about _______________________ and have lived separate and apart since that time.

2. A Petition for Dissolution of Marriage was filed with this Court on ______________.

3. That the Respondent signed an Entry of Appearance and Waiver or Response and

same was filed on __________________.

4. If the parties have children of the marriage, sixty (60) days have passed since the date

that the Respondent’s Entry of Appearance of Waiver was filled with the Court.

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FORM 11

5. A copy of separation agreement has been filed with the Court.

6. Jurisdictional proof has been filed with the Court.

7. The parties desire that the Court enter a Decree thereby dissolving their marriage in

conformance with the terms of the settlement agreement.

______________________________
PETITIONER, PRO SE (Signature)

______________________________
PETITIONER- printed name

______________________________
Street Address

______________________________
City, State, Zip Code

______________________________
Phone

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 is this action as listed below:

Name of other party: ____________________________________________

Street number and name: _________________________________________

City, State, ZIP: ________________________________________________

Telephone number: ______________________________________________

000
I have filed this Motion for a Divorce Decree with the Clerk of this __________ Circuit
Court and have mailed a copy to the other party involved in this action.

_____________________________
PETITIONER- Signature

Date: ________________________

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