FORM CC-1421 (MASTER, PAGE ONE OF TWO) 07/20
COURT USE ONLY
COURT USE ONLY
COURT USE ONLY
PETITION FOR PROCEEDING IN A NO-FAULT DIVORCE
WITHOUT PAYMENT OF FEES OR COSTS Case No. .........................................................................
COMMONWEALTH OF VIRGINIA VA.CODE § 17.1-606
............................................................................................................................................
Circuit Court
....................................................................................................................................... v. .......................................................................................................................................
The undersigned petitioner requests the court to permit the petitioner to proceed in a no-fault divorce case under Virginia Code § 20-
91(A)(9) in this court without the payment of fees or costs and to have from all officers all needful services and process. In support of
the petition, the petitioner states that the following information is true:
1. [ ] I currently receive the following type(s) of public assistance in ..................................................................................................................................
CITY/COUNTY
[ ] TANF $ .............................................. [ ] Medicaid [ ] Supplemental Security Income $ .....................................................
[ ] SNAP (food stamps) $ ............................................ [ ] Other (specify type and amount) ........................................................................
[ ] I am represented in this matter by a legal aid society, an attorney appearing as counsel pro bono, or an attorney assigned to
me or referred by a legal aid society.
If no boxes in this section are checked, complete sections 2 and 3 below. If one or both boxes in this section are checked,
skip section 2 and complete only section 3 below.
2. Names and address of employer(s) for myself and spouse:
Self ......................................................................................................................................................................................................................................................................
Spouse ...............................................................................................................................................................................................................................................................
NET INCOME:
Self Spouse
Pay period (weekly, every second week, twice monthly, monthly) ................................. ............................ ...........................
Net take home pay (salary/wages, minus deductions required by law and
tax withholdings)
$ ......................... ...........................
Other income sources (please specify)
........................................................................................................................................................................... $ ......................... ...........................
TOTAL INCOME $ ......................... + ........................... = A
LIQUID ASSETS:
Cash on hand
............................................................................................................................................. $ ......................... ...........................
Bank Accounts at: ................................................................................................................................... $ ......................... ...........................
Any other liquid assets: (please specify)
with a
............................................................................................................................ value of ......................... $ ......................... ...........................
.
TOTAL ASSETS $ ............................ + .............................. = B
EXCEPTIONAL EXPENSES (Total Exceptional Expenses of Family)
Medical Expenses (list only unusual and continuing expenses)
.................................................................... $ ..............................
Court-ordered support payments/alimony ............................................................................................................... $ ..............................
[ ] deducted from paycheck [ ] not deducted from paycheck
Child-care payments (e.g. day care)
........................................................................................................................... $ ..............................
Other (describe): ..................................................................................................................................................................
....................................................................................................................................................................................................... $ ..............................
TOTAL EXPENSE
S
$ .............................. = C
COLUMN “A” plus COLUMN “B” minus
COLUMN “C” equals available funds
=
.................. Number in household I have financial responsibility for, including myself.
