
Options:
Print the worksheet, complete and mail it to us. If you do not have a printer, e-mail us and we will send you a copy. CLICK HERE for a printable PDF version..
OR
Send the completed page by e-mail. (In your browser, click file, send, page by e-mail.) You will be placed in the queue when we receive your e-mail. Mail your payment and other required documents a.s.a.p.
| Your full name: | Occupation: |
| Address: | City: |
| Province: | Postal code: |
| Telephone # Home: | Business: |
| e-mail: | Fax: |
| Your date of birth: | Your surname at birth: |
| Your place of birth: | |
| Did the wife retain her maiden name? Yes No | |
| Province that you have habitually resided in for the past year: | |
| Your spouse's full name: | Occupation: |
| Address: | City: |
| Province: | Postal code |
| Telephone # Home: | Business: |
| e-mail: | Fax: |
| Spouse's date of birth: | Surname at birth: |
| Place of birth: | |
| Province that spouse has habitually resided in for the past year: | |
Name and address of Alberta
court registry (office) where you will file your divorce
action:
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Describe efforts made at reconciliation: (resumed cohabitation, saw a marriage counselor etc.)
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Describe with dates the beginning and end of any period (after separation) during which you and your spouse resumed cohabitation:
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| Your date and place of separation: | |
| Date of marriage | Place of marriage: |
| Wife's marital status at time of marriage: | Never married Widow Divorced |
| Husband's marital status at time of marriage: | Never married Widower Divorced |
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Name address and occupation of person who will serve your spouse with the divorce action: (Must be someone other than a spouse.)
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| Children: Full names, birth dates, of all children of the marriage if 19 years of age or under or dependant: | |
| Children have been resident in Alberta since: | |
| Children reside with: Husband Wife | Attend: Public school Private school |
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Attach copies of all Separation Agreements and court orders. If you have only a verbal agreement, describe in detail:
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Describe custody, access, and guardianship arrangements: (or attach relevant documents)
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| Has division of property and assets been settled? | Yes No |
| Complete this part only if there are children or you will be asking for spousal support. | |
| Amount of monthly child support paid: | Guideline table amount: |
| Amount of spousal support paid: | Arrears: No Yes Amount: |
| Are support payments made to the Maintenance Enforcement Program? Yes No | |
| Husband's gross annual income: | Total income from last tax return: |
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Husband's employer's name and address:
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Husband's income from other sources:
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| Wife's gross annual income: | Total income from last tax return: |
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Wife's employer's name and address:
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Wife's income from other sources:
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| Medical coverage for children paid by: Husband Wife | |
If you wish to proceed, complete the worksheet and mail with your payment of $300 to:
Joanne Tait-Stockton
ADR Mediation Services
R.R. # 1, Warsaw, Ontario,
K0L 3A0
Have you included a copy of all applicable required documents?
Separation Agreement Court Order Marriage Certificate Domestic Contract