1.     Name of Person Seeking Divorce:

2.     Address of Person seeking divorce:

         Address:
         City:           
         Province:   Postal Code:
         
         Phone #: 
         FAX:        
         E-mail:     

3.     Name of wife/husband you wish to divorce from:

4.     Date of Marriage:

5.     Place of Marriage:

6      Surname of yourself and husband/wife at Birth:

        Surname of Yourself: 
         
        Surname of Husband/Wife:
       

7.      At time of marriage the marital status of each party was, example single divorced.

         Yourself: 
          
         Husband/ Wife:
        

8.     The wife was born at on .

9.     The husband was born at on .

10.   The parties ceased cohabiting on .

11.   Address of person you wish to divorce from:

         Address:
         City:           
         Province:   Postal Code:
 

12.   Has one party been ordinary resident in the Province of British Columbia (BC)for at least one year preceding
         the date of filling in this Assessment Form?

         Yes      No

13.    Are grounds for Divorce possibly due to:

        None Adultery Mental Cruelty Physical Cruelty Both Mental and Physical Cruelty Other

14.    Is there a possibility of parties reconciling?

         Yes      No

15.    Any attempts at reconciliation been made?

         Yes      No

16.    Your place of employment:
        

         a. Gross Income:
        

         b. Total income (last tax return):
        

         c. Total taxable income (last tax return):
        

17.   Your wife/husband’s place of employment:
        

         a. Gross Income:
       

        b. Total income ( last tax return):
       

         c. Total taxable income (last tax return):
        

ONLY ANSWER THE PROCEEDING QUESTIONS 18-21 if you have children:

18.   Names and birth dates:

        Child: Date of Birth:
        Child: Date of Birth:
        Child: Date of Birth:
        Child: Date of Birth:

19.   Any special expenses for the children, example daycare, medical?

20.   Who do the child(ren) reside with now?

21.   Any agreements as to custody/access, please specify?

22.   What do you propose for custody/access/financial arrangements for the children?
        
       

23.   Provide details of any court proceedings, in regards to the marriage, custody, 
         access and support of the children or the parties as follows:
        
       

24.   Will parties agree on substantially all of the issues such as grounds for divorce,
        division of property, custody/access to children and child and spousal support?

         Yes      No

         If no, please specify what can be agreed to:

How would you like to correspond:

      Telephone Email Fax Mail