Field 1: Insert the county in which you are bringing the action.
Field 2: Print the Plaintiff's name.
Field 3: Insert the index number for the action.
Field 4: Print the Defendant's name.
Field 5: Insert the state and county where Plaintiff signed this document.
Field 6: Insert the Plaintiff's name.
Field 7: Print where the Plaintiff resides, the Defendant resides and their social security numbers.
Field 8: Address the residency requirements as explained on page two of this instruction booklet by checking the appropriate box or boxes.
Field 9: Insert the date the parties were married and the city, town or village; the county; and the state where they were married. Strike the italicized word "not" in the following sentence if the parties were married by a clergyman, minister or by a leader of the Society for Ethical Culture.
Field 10: If the word "not" is deleted, you must check one of the three options. Page 19

[Do not complete Fields 11-13 if there are no children of the marriage (see page 7)]

Field 11: List the number and names (if any) of the children of the marriage, their social security numbers, their dates of birth and the present address of each child as well as any other addresses they may have had for the previous five (5) year time period. You must also list the name and present address of the person that each child has lived with for the past five (5) years.
Field 12: Check the boxes as appropriate. If you check "yes", you must attach a statement explaining the circumstances, and if a Family Court order was issued, you must provide the court with a copy.
Field 13: Fill in the required information about Plaintiff's and Defendant's insurance coverage. Make sure to include the type of coverage, such as medical, dental or optical coverage. If either party has more than one insurance plan, you must list the additional coverage. Check the not applicable box if child support is not an issue or if there is no health insurance available to either party for the benefit of the child(ren) of the marriage.
Field 14: List the grounds for divorce, filling in any relevant facts to prove the grounds alleged. Refer to Grounds for Divorce on pages 2 through 5 of these instructions. See the bottom of the Summons With Notice (Form UD-1), which lists the different grounds for divorce, or if you filed a Summons and Verified Complaint, refer to paragraph 12 of the Complaint.
Field 15: At Section 6a, list any additional relief that you are requesting as “ancillary relief.” Refer back to p. 14 of these Instructions for the Summons with Notice and p.16 of these Instructions for the Verified Complaint forms. If you are waiving the distribution of marital property or if marital property is being distributed pursuant to an agreement/stipulation, check the appropriate box. You should also list any existing court orders (with the case/index/docket number) that you want to be continued or any stipulations or agreements that you have made in writing with the Defendant that you wish to become a part of the judgment.
Note: If DRL §170(7), is the ground alleged, you must check box A, B, C or D to affirm the statement required by Section 6b.
Field 16: Check the appropriate box as to the Defendant's status in the military. Strike the language that does not apply within the section that you choose.
Field 17: Strike the word "not" where appropriate.
Field 18: This section remains unchanged if there are no other matrimonial actions pending and you are still married. If there are other matrimonial actions pending, then you should seek legal assistance as noted in the Foreword.
Field 19: Leave this section unchanged if you have supplied a photograph of the Defendant to the process server. Strike or delete it if you have not.
Field 20: Check the appropriate box or boxes. If you are not the custodial parent, check Section 11A. If you are the custodial parent, check Section 11B and one of the following four statements [boxes (1),(2),(3), or (4)]. One of the four statements must be selected. If (1),(2) or (3) is selected in this Affidavit or in the Affidavit of Defendant, then you must check "Applicable" on the opening sentence (Field 8) of Form UD-11 (Judgment of Divorce).
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Field 21: Insert the Plaintiff's and/or the Defendant's surname before the marriage if different from the current surname.

Complete the rest of this section (D.R.L. §240 1 (a-1) Records Checking Requirements) only if there are minor children of the marriage (see the definition on page 7). Check the appropriate boxes and list any required information.

Field 22: The Plaintiff must sign the form before a notary public.