Form A1 - Auckland Justices of the Peace Association

rr 337(2)(b), 355(1)(a)(ii)
Form FP 14
Affidavit to accompany joint application
for order dissolving marriage or civil union
Section 38(2)(d), Family Proceedings Act 1980
FAM No: …………………….
In the Family Court
at ……………………………………
[place]
…………………
Svenja Katharina ZIELINSKI ……………..
[full name]
……98 Holy Links Pde, Wattle Downs, Auckland 1234.
[address]
……………
Primary School Teacher …………………………..
[occupation]
Applicant
…………………
Marc Franc PANZER …………………………..
[full name]
…3
Lucky St, Frankton, Hamilton ……………………..
[address]
……………………………
Insurance Broker …………………..
[occupation]
Applicant
[Set out full description of document (including whether it is made with or without
notice), its date, the Act under which the document is filed, and, in the case of an
affidavit or affirmation, the name of the deponent in whose support it is filed.]
Affidavit of
………….Svenja Katharina ZIELINSKI …… [name]
and
……………..Marc Franc PANZER ..……………[name]
in support of Joint Application for Order Dissolving Marriage or Civil Union
(Family Proceedings Act 1980)
dated…………………………………………………………………………
This document is filed by
[name and address for service, and, if filed by lawyers, the name and telephone
number of the acting lawyer.]
Svenja Katharina Zielinski
98 Holy Links Parade, Wattle Downs
Auckland 1234
P1/4 SKZ
MFP
JE B
2
I, ...………
Svenja Katharina ZIELINSKI………………..
[full name]
of 98 Holy Links Pde, Wattle Downs, Auckland 1234.
[address]
……………
affirm
Primary School Teacher ……………………
[occupation]
and I, ...………
Marc Franc PANZER …………………….………...
[full name]
of ...……
3 Lucky St, Frankton, Hamilton .……………….
[address]
………………………Insurance
Broker……………………………..
[occupation]
swear (or affirm) that:
1. We are the applicants for an order dissolving a marriage or civil union.
[select and complete the option that applies]
2. ………………………………………..............…………………………
[full name of one of the marriage (or civil union) partners]
is domiciled in New Zealand.
or
2. We are both domiciled in New Zealand.
3. We were married or entered into a civil union on …1
at …Parnell
………………
st
December 2007[date]
Rose Gardens, Parnell…….……….……….
[place]
Auckland……………………………………...……….
[name of city or town etc]
4. A copy of our marriage or civil union certificate is annexed to this affidavit
and marked with the letter A.
5. We are living apart.
6. We will, at the filing of the application, have been living apart for the period of
2 years immediately preceding the filing of this application.
7. We ceased living together on ………1st
May 2012...………….
[date]
P2/4 SKZ
MFP
JE B
3
[select and complete the option 8 that applies]
8. (a) A separation order was made on ………………………..… [date]
(b) A copy of the separation order is annexed to this affidavit and
marked with the letter B.
or
8. (a) A written separation agreement was made on ……….……. [date]
(b) A copy of the written separation agreement is annexed to this
affidavit and marked with the letter B.
or
8. We made an oral agreement to separate on
1st May 2012.
[date]
or
8. No separation order was made and we did not agree to separate.
9. Our marriage or civil union has broken down irreconcilably.
[Note: Select and complete paragraphs 10 and 11 if there are children of the
marriage or civil union.]
10. Satisfactory arrangements, or arrangements that are the best that may
be devised in the circumstances, have been made for the day-to-day
care, maintenance, and other aspects of the welfare of every child of
the marriage or civil union. The arrangements relate to every child who
is under 16 years. They also relate to every child who is 16 years or
over and who, because of special circumstances, requires arrangements
to be made.
11. The arrangements referred to in paragraph 10 of this affidavit are as
follows:
Day-to-day care:
[give details]
N/A
Maintenance:
[give details]
N/A
P3/4 SKZ
MFP
JE B
4
Other aspects of welfare, such as schooling or any special needs:
[give details]
Include if there are children of the marriage or civil union.
N/A
SKZielinski
………………………………....
Signature of deponent
MFPanzer
………………………………....
Signature of deponent
Severally Sworn (or affirmed) at …………AUCKLAND………....
[place]
this …23
rd
day of January 2015 ..
Joe Bloggs JP
Registration No 22929
Auckland
Justice of the Peace
for New Zealand
[date] before me:
JE BLOGGS ZJP
Registrar
(or Justice of the Peace
or Solicitor of the High Court)
………………………………....
Signature of deponent
Sworn (or affirmed) at ………………………………………...…………. [place],
this ………………………..………….. [date] before me:
………………………………....
Registrar
(or Justice of the Peace
or Solicitor of the High Court)
P4/4
“A”
5
BDM 109
New Zealand
Marriage Certificate
Particulars of Parties to Marriage
BRIDEGROOM
Marc Frank
Panzer
Svenja Katharina
Zielinski
First/given name(s)
Surname/family name
(If different First/given name(s) at birth__
from above) Surname/family name at birth__
Date and year of birth
Place of birth
Usual occupation, profession or job
Relationship status
Usual residential address
MOTHER: First or given name(s)
Surname or family name
Surname or family name at birth
(If different from above)
FATHER: First or given name(sJ
Surname or family name
__
__
25 April 1981
Hamburg Germany
23 January 1968
Hamburg Germany
Primary School Teacher
Never Married
Insurance Broker
Never Married
Bei der Reitbahn 3
Hamburg
Germany
Achtern Sand 39
Hamburg
Germany
Brigitte
Zielinski
Wahn
Helga
Panzer
Hardt
Frank Gerd
Panzer
__
Jorg Uwe
Zielinski
Surname or family name at birth__
(If different from above)
_
Date of marriage
01 December 2007
This is the document marked “A” referred to in the attached
declaration/affidavit of ___ Svenja Katharina ZIELINSKI
and Marc Franc PANZER
declared / sworn / affirmed at __ Auckland __
Place of marriage
Other information pursuant to sections__
Parnell Rose Gardens
Gladstone Road Parnell on, __23rd of January of 20_15
Auckland
before me ___ JE BLOGGS ZJP
59. 60. 62 or 62D of the Births, Death s,
and Marriages Registration Act 1995
by
he sea
egis
r
Joe Bloggs JP
Registration No 22929
Auckland
Justice of the Peace
For New Zealand
egis
(1) falsifies any of the particulars on
certificate
(
is liable to prosecution under