9. For each marriage give date of marriage, names and birth
dates of children born of the marriage, and date of separation,
divorce, or death:

B. Association with Third Persons

1. Have you ever had intercourse with anyone other than the defendant:

( ) yes

( ) no

2. Beginning and ending date of your last menstrual period preceding this pregnancy:

3. Did you have intercourse with other men two months preceding your last menstrual period and/or two months following your last menstrual period preceding this pregnancy?

( ) yes

( ) no If yes, give dates, names and

addresses of men involved:

4. Date you first learned you were pregnant:

5. Date on which defendant was informed of this pregnancy:

6. What did he say?

C. Illegitimate Child

1. If child is not yet born, expected date of birth:

A. Association with the Defendant

1. When and where did you first meet the defendant?

2. When and where did intercourse first occur?

3. Frequency and period of time during which intercourse
occurred:

7. Did you tell anyone else about your pregnancy:

If yes, whom and on what dates:

( ) yes
( ) no

8. Date on which you first contacted your doctor concerning this pregnancy:

D. Post Birth

1. Did the defendant visit you and the baby while you were in the hospital? ( ) yes ( ) no

If yes, give dates and names of persons who saw him visit:

2. Did you and the defendant have plans for marriage:

( ) yes

( ) no If yes, give details:

3. Did defendant offer to pay for your expenses:

( ) yes

( ) no If yes, what expenses:

4. Has the defendant visited the baby at home: () yes () no If yes, give dates, details and names and addresses of people who saw him visit:

5. List specific instances when the defendant has indicated that he is the father of your child; give dates, places, and names and addresses of other people present:

6. Do you have notes, diary, calendar or other records of
your relationships with the defendant:

A. If other illegitimate children, give names, birthdates, names of fathers, and indicate whether or not there has been an adjudication or acknowledgment of paternity:

B. Witnesses who have seen you with the defendant:

Witness

Address

Plaintiff:

Telephone No.