"Divorce Client Intake Form"

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DIVORCE CLIENT INTAKE FORM
Date: _____________
1. STATISTICAL INFORMATION:
CLIENT:
Client Name: _____________________________________________________
Client’s Maiden Name: _____________________________________________
Address: ________________________________________________________
County: _________________________________________________________
Date of Birth: _____________________________________________________
Place of Birth: ____________________________________________________
Social Security Number: ____________________________________________
Race: ___________________________________________________________
Employment: _____________________________________________________
Address of Employment: ____________________________________________
Occupation: ______________________________________________________
Number of Previous Marriages: ______________________________________
How were marriages terminated? _____________________________________
Current Military Service? ____________________________________________
Education: (Highest level completed) __________________________________
SPOUSE:
Spouse’s Name: __________________________________________________
Spouse’s Maiden Name: ____________________________________________
Address: ________________________________________________________
County: _________________________________________________________
Date of Birth: _____________________________________________________
Place of Birth: ____________________________________________________
Social Security Number: ____________________________________________
Race: ___________________________________________________________
Employment: _____________________________________________________
Address of Employment: ____________________________________________
Occupation: ______________________________________________________
Number of Previous Marriages: ______________________________________
How were the marriages terminated? __________________________________
Current Military Service? ____________________________________________
Education: (Highest level completed) __________________________________
MARRIAGE INFORMATION:
Date of Marriage: _________________________________________________
City and State Where Married: _______________________________________
Date of Separation: ________________________________________________
CHILDREN’S INFORMATION:
Names (oldest to youngest): ________________________________________
DIVORCE CLIENT INTAKE FORM
Date: _____________
1. STATISTICAL INFORMATION:
CLIENT:
Client Name: _____________________________________________________
Client’s Maiden Name: _____________________________________________
Address: ________________________________________________________
County: _________________________________________________________
Date of Birth: _____________________________________________________
Place of Birth: ____________________________________________________
Social Security Number: ____________________________________________
Race: ___________________________________________________________
Employment: _____________________________________________________
Address of Employment: ____________________________________________
Occupation: ______________________________________________________
Number of Previous Marriages: ______________________________________
How were marriages terminated? _____________________________________
Current Military Service? ____________________________________________
Education: (Highest level completed) __________________________________
SPOUSE:
Spouse’s Name: __________________________________________________
Spouse’s Maiden Name: ____________________________________________
Address: ________________________________________________________
County: _________________________________________________________
Date of Birth: _____________________________________________________
Place of Birth: ____________________________________________________
Social Security Number: ____________________________________________
Race: ___________________________________________________________
Employment: _____________________________________________________
Address of Employment: ____________________________________________
Occupation: ______________________________________________________
Number of Previous Marriages: ______________________________________
How were the marriages terminated? __________________________________
Current Military Service? ____________________________________________
Education: (Highest level completed) __________________________________
MARRIAGE INFORMATION:
Date of Marriage: _________________________________________________
City and State Where Married: _______________________________________
Date of Separation: ________________________________________________
CHILDREN’S INFORMATION:
Names (oldest to youngest): ________________________________________
________________________________________________________________
Date(s) of Birth: __________________________________________________
Social Security Number(s): _________________________________________
ADDRESSES: (Where and with whom the children have lived for the last 5 years)
__________________________________________________________
________________________________________________________________
2. OPPOSING ATTORNEY:
Name: __________________________________________________________
Docket Number: __________________________________________________
Next Court Date and Time: __________________________________________
3. DEBTS OF THE MARRIAGE:
Name of Creditor: _________________________________________________
Amount Owed: ___________________________________________________
Acct Number: ____________________________________________________
Who will pay debt? ________________________________________________
)
(Attach additional sheet if necessary
4. REAL ESTATE:
1.
Real Estate located at: ________________________________________
Who owns the property? ______________________________________
Debt Amount: _______________________________________________
Lender’s name and address: ___________________________________
Account Number: ____________________________________________
Who will assume and pay debt: _________________________________
2.
Real Estate located at: ________________________________________
Who owns the property? ______________________________________
Debt Amount: _______________________________________________
Lender’s name and address: ___________________________________
Account Number: ____________________________________________
Who will assume and pay debt: _________________________________
5. PERSONAL PROPERTY:
Please list all of the valuable items of personal property that will be, or may be in
dispute, the value of each, and who should receive the property.
Property
Value
Who receives?
6. FINANCIAL/BANKING ACCOUNTS:
Client: __________________________________________________________
Spouse: _________________________________________________________
7. ATTORNEY FEES/COURT COSTS:
How will attorney fees be paid? ______________________________________
Who will be responsible for Court costs? (Split, Client, or Spouse) ___________
8. AUTOMOBILES:
Client’s: Make Model Year Amount of Debt Lender Value
Spouse’s: Make Model Year Amount of Debt Lender Value
9. OTHER VEHICLES:
Boats, ATVs, Jet Ski, Tractors, Riding Lawnmowers
Name Debt Who will assume debt and item?
10. RETIREMENT: 401K, IRAs, Stocks and Bonds:
1.
Type of account:
___________________________________________
Name of account:
___________________________________________
Owner of account:
___________________________________________
2.
Type of account:
___________________________________________
Name of account:
___________________________________________
Owner of account:
___________________________________________
11. RESTORATION OF FORMER/MAIDEN NAME?
_____________________
12. INSURANCE:
Husband
Company:
_____________________________________________________
Policy No.:
_____________________________________________________
Wife
Company:
_____________________________________________________
Policy No.:
_____________________________________________________
13. CHILD SUPPORT WORKSHEET and PARENTING PLAN
INFORMATION:
NUMBER OF DAYS IN CUSTODY OF EACH PARENT:
Child’s Name: ____________________________________________________
# of days with Mother: _____________
# of days with Father: ______________
Child’s Name: ____________________________________________________
# of days with Mother: _____________
# of days with Father: ______________
INCOME: (Gross Monthly)
Mother:
______________________
Father:
______________________
HEALTH INSURANCE PREMIUM:
PAID BY: ________________________________________________________
PAID BY: ________________________________________________________
CHILDCARE COSTS:
PAID BY: ________________________________________________________
PAID BY: ________________________________________________________
RECURRING MEDICAL EXPENSES:
_________________________________
OTHER EXPENSES ROUTINELY PAID:
______________________________
Such as music, private school, athletics etc. describe
SUPPORT OF OTHER CHILDREN
If you or your spouse are supporting other children, please provide their names, dates of
birth, amounts paid, and Docket #: ____________________________
Please send this completed form to bpl@brennanlenihanlaw.com.