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This page links to an example of a completed form. This is the actual form with sample text added in each section.
You should make sure that your form relates to your circumstances. If you need more help to prepare your form, you should get legal advice.
Do not try to file this sample form.
This sample form is provided in Word format.
Sample Affidavit – Separation under one roof (54.7KB)
For more information about completing this form, see Instructions for completing an Affidavit – Separation under one roof.