1. What is your name?

2. What is the name of your husband/wife?

3. How old are you and your husband/wife?

4. How did you and your husband/wife meet?

5. Do you have a child or children?

6. What are the names of your children?

7. How old are they?

8. Where do you live?

9. When did you get married?

10. Where did you get married?

11. How many years are you married?

12. Do you have any marriage settlement regarding your properties?

13. Do you and your husband/wife owned properties during your marriage?

14. How many properties do you have and your husband/wife?

15. Did you and your husband/wife incur any debt/obligation during your marriage?

16. If yes, can you name your creditors?

17. Why do you want to file a petition for legal separation? Please encircle the
following ground(s)/reason(s):

(a) Repeated physical violence or grossly abusive conduct directed against the
petitioner, a common child, or a child of the petitioner;

(b) Physical violence or moral pressure to compel the petitioner to change

religious or political affiliation;

(c) Attempt of respondent to corrupt or induce the petitioner, a common child, or

a child of the petitioner, to engage in prostitution, or connivance in such
corruption or inducement;

(d) Final judgment sentencing the respondent to imprisonment of more than six
years, even if pardoned;

(e) Drug addiction or habitual alcoholism of the respondent; chan robles virtual
law library

(f) Lesbianism or homosexuality of the respondent;

(g) Contracting by the respondent of a subsequent bigamous marriage, whether

in or outside the Philippines;

(h) Sexual infidelity or perversion of the respondent;

 (i) Attempt on the life of petitioner by the respondent; or

(j) Abandonment of petitioner by respondent without justifiable cause for more

than one year.

18. When did this ground(s) occur?

19. How many times did it occur?

20. How did it occur?