Application for Dissolution of Marriage

Page 1 of 2 OMB Control Number 1076-0094

Expires: 08/31/2008

APPLICATION FOR DISSOLUTION OF MARRIAGE

Pursuant to 25 CFR 11.606 (c) the petitioner files this verified petition for the dissolution of marriage between the plaintiff and defendant:

Petitioner_________________________ Address ____________________________

Age ____ Occupation _____________________ Length of residence __________

Respondent_________________________ Address ___________________________

Age ____ Occupation ________________________ Length of residence __________

Date of marriage__________Place marriage was registered_____________________

Does the petitioner stipulate that the marriage is irretrievably broken in that either: (1) the parties have lived separate and apart for a continuous period of more than 180 days or (2) there is a serious marital discord adversely affecting the attitude of one or both of the parties toward the marriage and there is no reasonable prospect of reconciliation. ____ Yes ____ No

List all living children of the marriage:

_____________________________ ____ _____________________________________

Name Age Address

_____________________________ ____ _____________________________________

Name Age Address

(Continue on separate sheet if necessary)

Is the wife pregnant? ____ Yes ____ No

Describe any arrangements relative to the support of the children (including visitation rights and provision for custody) and spousal maintenance (continue on separate sheet if necessary):

VERIFICATION

I, _______________________________, Petitioner, being duly sworn to tell the truth and being of lawful age, hereby, state that I have prepared and read the factual information provided above and I declare under penalty of perjury that the foregoing is true and correct to the best of my personal knowledge.

___________________________________

Signature

Subscribed and sworn to before me this ____ day of ____________________, 20__.

(SEAL)

_____________________________

Court Clerk

Page 2 of 2 OMB Control # 1076-0094

Expires: 08/31/2008

PRIVACY ACT STATEMENT

This information collection document contains information that is covered under the Privacy Act, as amended. The Bureau of Indian Affairs will not disclose any record containing such information without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary use of this information is to assist eligible Indian individuals to obtain a decree for dissolution of marriage. Additional disclosure of the information may be made to: a Bureau of Indian Affairs or Department of the Interior employee in the course of a program review or audit; or to a Federal law enforcement agency when the agency becomes aware of a violation or possible violation of civil or criminal law. Furnishing the information on this form is required to establish eligibility for a decree for dissolution of marriage.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to assist eligible Indian individuals to obtain a decree for dissolution of marriage. You are not required to respond to this collection of information unless it displays a current and valid OMB control number. This information will be used to determine the jurisdictional authority of the Court of Indian Offenses and the eligibility of the petitioner for a decree for dissolution of a marriage. Voluntary and complete responses to the requests for information are required in order to obtain the decree requested.

ESTIMATED BURDEN STATEMENT

Public reporting burden for this form is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to: Bureau of Indian Affairs Information Collection Clearance Officer, 625 Herndon Parkway, Herndon, VA 20170-5416.