First Name Last Name E-mail Address Street Address City State/Prov Zip/Postal Code Home Phone Business Phone Middle Name County in which you live Do you live in (choose one)
---Select--- \nA Town
B City
C Village
Specify name of town, city or village Maiden Name (or Maiden Name of Spouse) Social Security Number Date of Birth Spouse's Full Name (first, middle, last) Spouse's Address Spouse's County Does Spouse live in (choose one)
---Select--- \nA Town
B City
C Village
Specify name of town, city or village Spouse's Social Security Number Spouse's Date of Birth Date of Marriage Location of Marriage (include city, state and county) Type of Marriage (select one)
---Select--- \nA Religious
B Civil
C
Date of Separation Number of children of this marriage Names of Children, Dates of Birth and Social Security Numbers Numer of this marriage (first, second, etc.) Number of this marriage for spouse (first, second, etc.) If you were previously married, how many ended in death? If previously married, how many ended in divorce or annulment? If spouse was previously married, how many ended in death? If spouse was previously married, how many ended in divorce or annulment? Race (choose one)
---Select--- \nA White
B Black American
C American Indian
D Asian
E Hispanic
F Other
Highest grade of education completed Spouse's Race (choose one)
---Select--- \nA White
B Black American
C American Indian
D Asian
E Hispanic
F Other
Highest grade of education completed by spouse Place of Employment Yearly Income Spouse's place of employment Spouse's yearly income Name of parent covering children with health insurance Name of insurance company Condition of your health (choose one)
---Select--- \nA Poor
B Fair
C Good
E Excellent
Condition of spouse's health (choose one)
---Select--- \nA Poor
B Fair
C Good
E Excellent
Residency Requirement (select one)
---Select--- \nA Both spouses currently live in New York AND the cause of the divorce happened in New York
B At least one spouse has lived in New York for the past two years
C At least one spouse has lived in New York for the past year AND couple was married in New York
D At least one spouse has lived in New York for the past year AND couple lived in New York while married
E At least one spouse has lived in New York for the past year AND the cause of the divorce occurred in New York
Grounds for Divorce (select one)
---Select--- \nA Cruel and Inhumane Treatment
B Abandonment
C Conversion Divorce
Explain reasons for divorce. Include 3 examples with approximate dates (no more than 5 years ago)
