| PLAINTIFF | |||
| ADDRESS: |
| AGE: | CITIZENSHIP: |
| TELEPHONE # |
| DEFENDANT |
| ADDRESS: | |||
| AGE: | CITIZENSHIP: |
| Exact date and place of marriage: | |||
| Maiden name of wife: |
| Is Maiden name to be restored? | Yes | No | |||||
| Is a former married name to be restored? | Yes | No |
| If yes, state former married name: |
| Names of minor children: (Under age 18) |
| 1. | 4. | |||||
| 2. | 5. | |||||
| 3. | 6. |
| Custody of minor children with: | Mother: | Father: | Joint: |
| There is (is not) a separation agreement, dated: |
| Passport No. | Issued at |
| Social Security Card No. | |||
| Driver's License No. |
| The plaintiff who will appear in Haiti must bring one of the following: a passport, a birth certificate, voters registration card, social security card or drivers license. The original or photocopy of the marriage certificate must be in the possession of the plaintiff in court. A notarized affidavit by the plaintiff stating the exact date and place of marriage, the name of the husband and maiden name of the wife, may be used in lieu of the marriage certificate. The information stated above is true to the best of my knowledge. |
| Signature of the Plaintiff |