I hereby certify that I have examined the record or conformed copies of all pleadings in the above-captioned case and the
information provided herein is true and correct based upon my personal knowledge, information, and belief.
Notice: Must be completed by Mover or his/her attorney and submitted/filed with the Judgment of Divorce.
Petition for Divorce:
Date Petition Filed
Parties physically separated: Date of Separation
Service of the Petition:
If Sheriff’s return is in the record, indicate the date and type of
Personal/Domiciliary (Circle one) Date of Service
If Domiciliary, then name of person served and the relationship ______________.
If a Waiver of Service is filed into the record, provide dates of
execution and filing: Date Waiver Executed
Date Waiver Filed
Is the Petition for Divorce in the record? Yes
Are proper jurisdiction and venue expressly alleged in the Petition? Yes
Are both parties represented by counsel? Yes
Has each party, through his/her counsel, filed a written joint stipulation of facts,
request for judgment, and sworn verification?
Have counsel for the parties filed a proposed judgment containing a
certification that counsel and each party agree to the terms thereof?
C. Time Periods (La. C.C. Art. 103.1)
(Choose either #1 or #2)
The parties have minor children and have been living separate and apart 365 days or more
The parties have no minor children and have been living separate and apart 180 days or more
NOTICE: If an attorney for absent defendant has been appointed, this procedure cannot be used. Petitioner and the appointed attorney must
appear in court.
Date of Record
Signed by Petitioner/Attorney for
LOUISIANA CIVIL CODE ARTICLE 103(1)
Uncontested Divorce Under Code of Civil Procedure Article 969(B)
APPENDIX 28.2B: LA. C.C.P. ART. 969(B) DIVORCE CHECKLIST
HEARING OFFICER RECOMMENDATION
Considering the record in this case, the submission of the parties or their counsel, it being the finding of the hearing officer
that all legal requirements for granting a divorce under Louisiana Civil Code Article 103(1) have been met.
IT IS HEREBY recommended that the attached Judgment of Divorce be made the Order of this Court, no objection having
been made by either party.
_, Louisiana, this _ day of , 20 .