Fill and Sign the Custody Litigation Client Information Form Minnesota

CUSTODY INFORMATION FORM It is essential for you to try to answer all of the questions on the following pages as completely as possible. The availability of complete, accurate information will assist your attorney to represent you effectively and efficiently and, thus, reduce the cost of litigation. In addition to the questions you answer on this form, you will be asked to submit all financial data that confirm and document your answers. Please send any such documentation currently in your possession at the time you return this form. If any question does not apply to you or your situation, please go on to the next question. Date of Interview: ___________ Referred By: ___________ INFORMATION ABOUT THE CHILD(REN) WHOSE CUSTODY IS AT ISSUE FULL NAME BIRTHDATE AGE PERSON WITH WHOM THE CHILD IS NOW LIVING 1. ___________ ___________ _____ ________________ 2. ___________ ___________ _____ ________________ 3. ___________ ___________ _____ ________________ 4. ___________ ___________ _____ ________________ Attach an additional sheet if needed to complete this section . Is a custody order now in effect? yes no. Please attach a copy of any existing order. Is the parentage, mother-child or father-child relationship, of the child(ren) in dispute? yes no. If yes, explain. ______________________________________ ______________________________________ Use additional sheets if necessary to complete this answer . What is your relationship to the child(ren) whose custody is in dispute? ______________________________________ ______________________________________ - 1 - PERSONAL INFORMATION CLIENT Your full name ______________________________________ (Last) (First) (Middle) All former names ______________________________________ Age ___ Date of birth ___________ Soc. Security No . ___________ Mo./Day/Year Present address ______________________________________ If you do not wish to receive your bill or other correspondence at the above address, please provide an alternative mailing address. ______________________________________ How long have you lived at this address? ______________________________________ Telephone: (Home) ___________ (Work) ___________ (Other) ___________ Last prior address ______________________________________ Nationality if other than U.S. citizen ______________________________________ OCCUPATION INFORMATION CLIENT Your occupation ______________________________________ Employer's name ______________________________________ Employer's Address ______________________________________ ______________________________________ Employer's phone number ______________________________________ Length of employment ______________________________________ CLIENT EDUCATION - 2 - Highest level of education you have attained ______________________________________ List any certificates or degrees that you hold ______________________________________ PRESENT MARRIAGE CLIENT Are you presently married? yes no. If yes, answer the following questions: Spouse's name ______________________________________ All former names ______________________________________ Age ___ Date of birth ___________ Soc. Security No . ___________ Mo./Day/Year Present address (if different than your address) ______________________________________ OTHER CHILDREN CLIENT Do you have children other than the child(ren) whose custody is in dispute? yes no. If yes, provide the information requested below: FULL NAME BIRTHDATE AGE PERSON WITH WHOM THE CHILD IS NOW LIVING 1. ___________ ___________ _____ ___________ 2. ___________ ___________ _____ ___________ 3. ___________ ___________ _____ ___________ 4. ___________ ___________ _____ ___________ Attach an additional sheet if needed to complete this section. Is a custody order now in effect? yes no. Please attach a copy of any existing order. Are you paying , receiving , support for any of these children? Number of child(ren) ____ Age(s) of child(ren) ___________ State the amount the child support you pay/receive $ ___________ - 3 - What amount, if any, is delinquent? ______________________________________ PRIOR MARRIAGES CLIENT Were you previously married? ___ Number of previous marriages ___________ If previous marriage(s) ended by dissolution (divorce), when and where did the dissolution action(s) occur? ___________ ___________ ___________ ___________ (Month/Year) (City) (County) (State) ___________ ___________ ___________ ___________ (Month/Year) (City) (County) (State) Do you receive ___ , pay ___ , maintenance (alimony)? yes no If yes, what is the amount? $ _________________________________ What amount, if any, is delinquent? $ _________________________________ - 4 - PERSONAL INFORMATION OPPOSING PARTY Opposing party's full name _________________________________ (Last) (First) (Middle) Opposing party's former name(s) _________________________________ Age ___ Date of birth ___________ Soc. Security No. ___________ Mo./Day/Year Present address _________________________________ Telephone: (Home) ___________ (Work) ___________ (Other) ___________ Nationality if opposing party is other than U.S. citizen ___________ Opposing party's occupation _________________________________ Employer's name _________________________________ Employer's address _________________________________ _________________________________ Employer's phone number _________________________________ Length of employment _________________________________ Highest level of education the opposing party has attained ___________ List any certificates or degrees that the opposing party holds _________________________________ What is your relationship to the opposing party? _________________________________ What is this opposing party's relationship to the children whose custody is in dispute? _________________________________ Is this opposing party presently married? yes no If yes, provide spouse's name, address, phone number and occupation. _________________________________ _________________________________ _________________________________ _________________________________ - 5 - _________________________________ _________________________________ Has this opposing party been previously married? yes no If yes, provide the following information: Number of previous marriages ___________ If previous marriage(s) ended by dissolution (divorce), when and where did the dissolution action(s) occur? ___________ ___________ ___________ ___________ (Month/Year) (City) (County) (State) ___________ ___________ ___________ ___________ (Month/Year) (City) (County) (State) MULTIPLE PARTIES If there will be more than one opposing party (for example, grandparents and a parent, or a friend and a relative) provide the information requested above for each opposing party. Use additional sheets if needed. Opposing party's full name ________________________________________________ (Last) (First) (Middle) Opposing party's former name(s) ______________________________________ Age ___ Date of birth ___________ Soc. Security No. ___________ Mo./Day/Year Present address ______________________________________ Telephone: (Home) ___________ (Work) ___________ (Other) ___________ Nationality if opposing party is other than U.S. citizen ___________ Opposing party's occupation ______________________________________ Employer's name ______________________________________ Employer's address ______________________________________ ______________________________________ Employer's phone No. ______________________________________ Length of employment ______________________________________ Highest level of education the opposing party has attained ___________ List any certificates or degrees that the opposing party holds ______________________________________ _________________________________ - 6 - What is your relationship to the opposing party? ______________________________________ _________________________________ What is this opposing party's relationship to the children whose custody is in dispute? _________________________________ _________________________________ What is this opposing party's relationship to the other opposing parties? _________________________________ _________________________________ CLIENT CONTACT In the event that this office must reach you on short notice, give the name, address, and telephone number of a person who is most likely to know where to locate you. ___________________________________________________ (Name) (Phone) _________________________________ _________________________________ (Address) Relationship to you? _________________________________ - 7 - MONTHLY EXPENSES Please complete the following section as accurately as possible. Do not underestimate your expenses. If you share expenses with another person, list that person's contribution on the form marked EXPENSES PAID BY ANOTHER . If you have expenses for a child or children that are not included in court ordered child support payments, list those expenses on the form marked CHILDREN'S EXPENSES . MONTHLY EXPENSES It is essential that you accurately determine what your monthly expenses are. Please review your check register as well as noting cash expenditures. If some of your expenses are paid quarterly or yearly, divide that expense by 3 or 12 respectively to arrive at the monthly expense figure. Necessary Monthly Expenses: Your expenses Children's Expenses (a) Rent $ ________ $ ________ (1) Rental insurance $ ________ $ ________ (b) Mortgage $ ________ $ ________ (c) Contract for deed payment $ ________ $ ________ (d) Homeowner's insurance $ ________ $ ________ (e) Real estate taxes $ ________ (f) Utilities (1) Gas ________ (2) Electric ________ (3) Phone ________ (4) Water ________ (g) Heat ________ (h) Food (1) Groceries ________ (2) Dining out ________ (3) Liquor ________ (i) Clothing ________ (j) Laundry and dry cleaning ________ (k) Medical and dental ________ (Includes: insurance premiums, eye glasses, medical equipment, drugs and prescriptions) (l) Transportation ________ (Includes _______ car payment, gas, oil, repairs and maintenance, auto club membership, garage rental, parking) (m) Car insurance ________ (n) Life insurance ________ (o) Recreation, entertainment and travel ________ (p) Newspapers and magazines ________ (q) Social and church obligations ________ (r) Personal allowances and incidentals ________ (includes cigarettes, haircuts, beauty aids) (s) Home maintenance (1) Repairs ________ - 8 - (2) Supplies and hardware ________ (3) Furniture and appliance purchases ________ (4) Yard service ________ (5) Assessments ________ (6) Shrubbery and flowers ________ (7) Garbage removal ________ (t) Court ordered spousal maintenance ________ (u) Court ordered child support ________ (v) Additional information ________ ________ re: Debts and expenses ________ ________ TOTAL: $ ________ Necessary Monthly Expenses: Expense Paid (a) Rent $ ________ $ ________ (1) Rental insurance ________ ________ (b) Mortgage ________ ________ (c) Contract for deed payment ________ (d) Homeowner's insurance ________ (e) Real estate taxes ________ (f) Utilities (1) Gas ________ (2) Electric ________ (3) Phone ________ (4) Water ________ (g) Heat ________ (h) Food (1) Groceries ________ (2) Dining out ________ (3) Liquor ________ (i) Clothing ________ (j) Laundry and dry cleaning ________ (k) Medical and dental ________ (Includes: insurance premiums, eye glasses, medical equipment, drugs and prescriptions) (l) Transportation ________ (Includes _____ car payment, gas, oil, repairs and maintenance, auto club membership, garage rental, parking) (m) Car insurance ________ (n) Life insurance ________ (o) Recreation, entertainment and travel ________ (p) Newspapers and magazines ________ (q) Social and church obligations ________ (r) Personal allowances and incidentals ________ (includes cigarettes, haircuts, beauty aids) (s) Home maintenance - 9 - (1) Repairs ________ (2) Supplies and hardware ________ (3) Furniture and appliance purchases ________ (4) Yard service ________ (5) Assessments ________ (6) Shrubbery and flowers ________ (7) Garbage removal ________ (t) Court ordered spousal maintenance ________ (u) Court ordered child support ________ (v) Additional information ________ ________ re: Debts and expenses ________ ________ TOTAL: $ ________ MONTHLY INCOME NOTE: To arrive at monthly income if received weekly, multiply weekly income by 52 and divide by 12; if received bi-W eekly, multiply bi-weekly income by 26 and divide by 12. Use same formula to convert your weekly or bi-weekly deductions to monthly figures. Income From Employment YOUR INCOME Gross monthly income $ ________ Deductions (state number of exemptions claimed and single or married withholding status) ________ ; Federal withholding $ ________ State withholding ________ FICA ________ Medical insurance ________ Pension or profit-sharing ________ Union dues ________ TOTAL $ ________ Life insurance ________ Credit union loans ________ Savings ________ Other: ________ ________ ________ ________ ________ ________ TOTAL $ ________ TOTAL MONTHLY DEDUCTIONS $ ________ Total net monthly income from employment $ ________ Other Income Net rental income $ ________ Dividends and interest ________ (monthly average) Social security ________ - 10 - Veterans' Administration benefits ________ Unemployment compensation ________ Other: ________ ________ ________ ________ _______ ________ Total other income $ ________ Total monthly income $ ________ Please list any employment benefits, such as a company car, travel and transportation allowances, expense accounts, bonuses, club memberships, and describe each such benefit, giving a value if possible. _________________________________________________________ ASSETS Please answer the following questions regarding your assets. If you have recently completed a Personal Financial Statement in acquiring a loan, please attach a copy of that to your sheet in addition to answering the following questions. Cash in Bank or at Financial Institution Bank/Financial Present Institution Account No. Type Balance ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Stocks, Bonds, Mutual Funds, and Other Securities Market Value or Value at # of Financial Maturity Brokerage Description Shares (specify) Institution (if any) ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ - 11 - Other Investments Description Value Valuation Method ______________________ ________ ______________________ ______________________ ________ ______________________ ______________________ ________ ______________________ ______________________ ________ ______________________ Use an additional sheet of paper if needed to complete this section. Life Insurance Face Cash Loan Insured Company Policy # Value Value Value ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ LIABILITIES Credit Card and Other Unsecured Debts Creditor's Balance Payment Per Name Due Month ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Use additional sheets as needed to complete this section. Secured Debts Creditor Balance Payment Description/Security Interest - 12 - ________ ________ ________ __________________ ________ ________ ________ __________________ ________ ________ ________ __________________ ________ ________ ________ __________________ Use additional sheets as needed to complete this section. MISCELLANEOUS PROPERTY Do you have any money or property held by others? yes no If yes, please explain _____________________________________ Are you the beneficiary under any estate now in probate? ________ If so, state which party, whose estate and approximate amount to be received __________ Are you the beneficiary under any trust? ________ If you are the beneficiary under a trust, please state by whom the Trust was established, the approximate value of your share of the Trust, and the annual income derived therefrom. _____________________________________ REAL PROPERTY Homestead Address: _____________________________________ Do you have a Certificate of Title to your home? _____________________________________ If so, where is it? _____________________________________ Legal description: _____________________________________ Date purchased ________ Price $ ________ In name of ________ Mortgage or contract for deed balance $ ________ Payable $ ________ per month Name of mortgage or contract for deed holder _____________________________________ Second mortgage or home improvement loan balance $ _______ Payable $ ________ per month Amount of real estate taxes $ ________ included in monthly payment of $ ________ Amount of insurance premium $ ________ included in monthly payment of $ ________ - 13 - Tax assessor's valuation $ ________ Your estimate of value $ ________ Other Real Estate (lake home, vacant land, rental property, etc.) Address _____________________________________ Type _____________________________________ Is this abstract or torrens property? _____________________________________ Legal description _____________________________________ Date purchased ________ Price $ ________ In name of ___________ Mortgage or contract for deed balance $ ________ Payable $ ________ per month Name of mortgage or contract for deed holder _____________________________________ Second mortgage or home improvement loan balance $ ________ Payable $ ________ per month Name of second mortgage or home improvement loan holder ________ Payable $ ________ per month Amount of real estate taxes $ ________ included in monthly payment $ ________ Amount of insurance premium $ ________ included in monthly payment $ ________ Tax assessor's valuation $ ________ Your estimate of value $ ________ If rental property, amount of monthly rental income $ ________ DEFERRED COMPENSATION PLANS How many years to retirement and/or distribution _____________________________________ Pension Plan (Defined Benefit Plan) Plan name _____________________________________ Plan # ________ Plan administrator _____________________________________ % of vesting ________ - 14 - Number of years to 100% vesting _____________________________________ Accrued monthly benefit $ _____________________________________ Present value (if known) $ _____________________________________ How did you determine present value? _____________________________________ Profit Sharing Account (Defined Contribution Plan) Plan name _____________________________________ Plan # ________ Plan administrator _____________________________________ % of vesting ________ Number of years to 100% vesting _____________________________________ Balance in account $ _____________________________________ Employee's contributions (if known) _____________________________________ Employer's contributions (if known) _____________________________________ Include 401(K) plans IRA'S Location of funds _____________________________________ Account # ________ Present value _____________________________________ Maturity date ________ Rate of interest ________ SEP'S or KEOGH'S Location of funds _____________________________________ Account # ________ Present value ________ Plan administrator _____________________________________ Loans _____________________________________ Other Retirement Benefits Type _____________________________________ Estimated value: $ ________ - 15 - BUSINESS INTERESTS If financial statements or statements of net worth have been completed regarding your business interest, please attach copies . Sole Proprietorships Proprietorship name _____________________________________ Business location _____________________________________ _____________________________________ Type of business _____________________________________ % of ownership ________ Years established ________ Last year Schedule C filed ________ Value (est.) $ ________ Valuation method _____________________________________ Is there a balance sheet for the business? ________ If so, who prepared it? _____________________________________ Partnership - General or Limited Partnership name _____________________________________ Business location _____________________________________ _____________________________________ Type of business _____________________________________ % of ownership ________ Years established ________ Last year partnership tax return (Form 1065) filed ________ Value (est.) $ ________ Valuation method _____________________________________ Is there a balance sheet for the partnership? ________ If so, who prepared it? _____________________________________ Corporations Name _____________________________________ - 16 - Business location _____________________________________ _____________________________________ Type of business _____________________________________ % of ownership ________ Years established ________ Last year corporate tax return filed ________ Value (est.) $ ________ Valuation method _____________________________________ Is this a Subchapter S corporation? ________ What is the fiscal year of the corporation? ________ A complete picture of the assets and income you have is necessary, either from information and documentation you can provide now or through the discovery process during the pendency of the proceeding. It will be of great assistance, saving time and expense, if you can provide the following at our first meeting or as soon as possible: 1. Your paycheck stubs from January 1 of the current year or the most recent stub showing year-to-date figures. 2. Savings passbooks and savings certificates for individual or joint accounts. 3. Copies of stocks or bonds owned by you along with the name of your broker or brokers. 4. Current statements relating to life insurance policies, along with statements of any loans against them. 5. A list of outstanding debts . 6. Any brochures or periodic statements describing pension, profit-sharing or stock purchase plans of your employer. 7. Copies of any financial statements or statements of net worth prepared by you either personal or for any business in which you have an ownership interest. 8. Copies of your State and Federal tax returns , including your W2 forms , for the past three (3) years. 9. Any brochures describing medical, hospitalization and dental insurance coverage you presently have. - 17 -