FORM 70.05A
No. |
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IN THE SUPREME COURT OF NOVA SCOTIA (FAMILY DIVISION) |
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BETWEEN: |
*[A.B.] - and - *[C.B.] |
Applicant/Petitioner Respondent |
APPLICATION AND INTAKE FORM
TAKE NOTICE that the Applicant/Petitioner *[name] has started a proceeding in the Supreme Court (Family Division), claiming the following relief:
☐ Under the Divorce Act: Petition for Divorce attached and setting out the relief claimed.
☐ Under the Maintenance and Custody Act, including the following sections as referenced in brackets:
☐ Custody (s. 18) ☐ Leave to apply (s. 18)
☐ Access (s. 18) ☐ Leave to apply (s. 18)
☐ Child maintenance [married parents] (s. 9)
☐ Child maintenance [unmarried parents including finding of paternity] (s. 11)
☐ Spousal maintenance (s. 3)
☐ Exclusive occupation of residence (s. 7)
☐ Order for paternity or blood tests (s. 27)
☐ Registration of Agreement (s. 52)
☐ Under the Matrimonial Property Act:
☐ Exclusive possession of matrimonial home
☐ Division of property
☐ Division of pension
☐ Other (specify) _____________________________________
☐ Under the Pension Benefits Act, the Pension Benefits Standards Act, 1985, or other applicable pension legislation to enable a division of pension
☐ Costs
☐ Other (specify, including jurisdiction or legislation governing relief sought)______________________________________________________________
A completed application and intake form is attached. Please review the information carefully to make sure that it is correct.
DATED at *[location], Nova Scotia, on *[date].
Applicant/Petitioner
TO: Respondent: __________________________
Please complete all Sections pertaining to your case. Please print.
Section A |
Information about you. (APPLICANT) |
Information about the person against whom you are making this application. (RESPONDENT) |
Name |
Last Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . First Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . Middle Name:. . . . . . . . . . . . . . . . . . . . . . . . . . Other/Previous Names:. . . . . . . . . . . . . . . . . . |
Last Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . First Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . Middle Name:. . . . . . . . . . . . . . . . . . . . . . . . . . Other/Previous Names:. . . . . . . . . . . . . . . . . . |
Gender |
☐ Male ☐ Female |
☐ Male ☐ Female |
Birth Date |
Day_____Month___________Year________ |
Day_____Month___________Year________ |
SIN |
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Telephone Fax |
Home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Message. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Email. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Message. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Email. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Address |
P.O. Box. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apt. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City/Town. . . . . . . . . . . . . . . . . . . . . . . . . . . . Province. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postal Code. . . . . . . . . . . . . . . . . . . . . . . . . . . Special Directions to Accommodate Service of Documents:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
P.O. Box. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apt. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City/Town. . . . . . . . . . . . . . . . . . . . . . . . . . . . Province. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postal Code. . . . . . . . . . . . . . . . . . . . . . . . . . . Special Directions to Accommodate Service of Documents:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Legal Counsel |
☐ Yes ☐ No ☐ Maybe If yes: Lawyer’s Name:. . . . . . . . . . . . . . . . . . . . . . . . Firm Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Email:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
☐ Yes ☐ No ☐Maybe If yes: Lawyer’s Name:. . . . . . . . . . . . . . . . . . . . . . . . Firm Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Email:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Section A |
Information about you. (APPLICANT) |
Information about the person against whom you are making this application. (RESPONDENT) |
Current Marital Status |
☐ Married ☐ Divorced ☐ Separated ☐ Common law relationship ☐ Single |
☐ Married ☐ Divorced ☐ Separated ☐ Common law relationship ☐ Single |
Income |
☐ Employment Income (salary/wages) ☐ Commission/Bonuses/Overtime ☐ Self-employed ☐ Income from a Partnership/Corporation ☐ Employment Insurance ☐ Social Assistance/Family Benefits ☐ Worker's Compensation ☐ Pension Income ☐ Income from a Trust ☐ Other Explain:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
☐ Employment Income (salary/wages) ☐ Commission/Bonuses/Overtime ☐ Self-employed ☐ Income from a Partnership/Corp oration ☐ Employment Insurance ☐ Social Assistance/Family Benefits ☐ Worker's Compensation ☐ Pension Income ☐ Income from a Trust ☐ Other Explain:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Occupation |
Occupation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employer Information Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone Number:. . . . . . . . . . . . . . . . . . . . . . . . . Email:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Other Places of Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Occupation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employer Information Name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone Number:. . . . . . . . . . . . . . . . . . . . . . . . . Email:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Other Places of Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Section B |
Relationship Between Applicant and Respondent |
☐ Married Date of Marriage:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Separation:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Common Law Date common-law relationship began: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Separation:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Divorced Date of Divorce Judgment:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ☐ Single ☐ Parent of Applicant's Child ☐ Other Explain:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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Section C |
List below the full names and dates of birth of all children who are the subject of this Application. |
Last Name |
Given Names (underline name used) |
Date of Birth |
Gender (M/F) |
Presently Living With: |
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Section D |
Most Recent Court Order or Written Agreement |
Most Recent Court Order (if any): Date Issued:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Court: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . File Number:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Most Recent Written Agreement (if any): Date:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |