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N re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: and Co-Petitioner/Respondent: COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg. #: Courtroom SWORN FINANCIAL STATEMENT I, (full name) am am not currently employed. I am employed hours.

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