Fill and Sign the Information Form Sheet Download

PATERNITY 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: _______________ PERSONAL INFORMATION CLIENT Your full name _____________________________________________________________ (Last) ---------- (First) (Middle) 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 _______________ PERSONAL INFORMATION - 1 - OPPOSING PARTY Opposing Party's full name ________________________________________ (Last ---------- (First) (Middle) 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 _______________ NATURE OF RELATIONSHIP WITH OPPOSING PARTY Child(ren) born of this relationship: PERSON WITH WHOM THE CHILD IS NOW LIVING FULL NAME BIRTHDATE AGE 1. ____________________ __________       2. ____________________ __________       3. ____________________ __________       4. ____________________ __________       5. ____________________ __________       Attach an additional sheet if needed to complete this section. Is there a current pregnancy involved in this case?       On what date did you first meet the opposing party? __________ Where did you first meet the opposing party? ____________________ - 2 - What date(s) did you and the opposing party engage in sexual intercourse? ________________________________________ At what time of the day did each act of sexual intercourse occur? Please specify the exact time if you know it, i.e., 10:00 p.m. ________________________________________ Where did you and the opposing party engage in sexual intercourse, i.e., at your apartment, her apartment, what room in the apartment? ________________________________________ ________________________________________ Was any contraceptive device used by you? yes no If yes, what type(s) of contraceptive device did you use? ____________________ Was any contraceptive device used by the opposing party? yes no If yes, what type(s) of contraceptive device did the opposing party use? __________________ Were any chemicals used by you and/or the opposing party? yes no If yes, what chemicals were used and who used the chemicals? ____________________ Were you impotent at the time you and the opposing party engaged in sexual intercourse? ________________________________________ Were you sterile at the time you and the opposing party engaged in sexual intercourse? ________________________________________ Do you know whether the opposing party engaged in sexual intercourse with any other man during the time of conception? Yes No If yes, please provide the name and address of each man. ________________________________________ ________________________________________ ________________________________________ Has a blood test been taken in this paternity action? Yes No If a blood test has been taken, did you have a blood transfusion during the three (3) months prior to the date the blood was drawn? ____________________ If a blood test has not been taken, have you had a blood transfusion during the past three (3) months? Yes No On what date did you first learn of the opposing party's pregnancy? ____________________ - 3 - Who informed you of the pregnancy? ____________________ If the opposing party informed you of the pregnancy, did she inform you in person, by telephone or by letter? ____________________ Please state in detail what was said in any conversation between you and the opposing party regarding the pregnancy. ________________________________________ _______________________________________ _ ________________________________________ ______________________________________ __ ________________________________________ _____________________________________ Attach an additional sheet if needed to complete this question . Have you paid any money to the opposing party? ____________________ If you have paid the opposing party money, how much have you paid to date? ________________________________________ Have you spoken or corresponded with the opposing party since the child's birth? Yes No If you have spoken with or corresponded with the opposing party, please state in detail what was said. ________________________________________ _______________________________________ _ ________________________________________ ______________________________________ __ ________________________________________ _____________________________________ Attach an additional sheet if needed to complete this question. - 4 - PRIOR MARRIAGE INFORMATION CLIENT Were you previously married? Yes ------ No (If not, skip to Prior Marriage Information-Opposing Party Section below) 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) Are you obligated to pay child support for child(ren) of a previous relationship? Yes No If yes, what is the amount? $___________ per __________ Number of child(ren)       Age(s) of child(ren) _______________ What amount, if any, is delinquent? $ PRIOR MARRIAGE INFORMATION OPPOSING PARTY Has the opposing party been previously married? Yes No (If not, skip to Occupation Information-Client Section on page 6) 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) OCCUPATION INFORMATION - 5 - CLIENT Your occupation ______________________________ Employer's name ______________________________ Employer's address ______________________________ ______________________________ Employer's phone number ______________________________ Length of employment ______________________________ OCCUPATION INFORMATION OPPOSING PARTY Opposing Party's occupation ______________________________ Employer's name ______________________________ Employer's address ______________________________ ______________________________ Employer's phone number ______________________________ Length of employment ______________________________ CLIENT EDUCATION Highest level of education you have attained ______________________________ List any certificates or degrees that you hold ______________________________ ______________________________ OPPOSING PARTY'S EDUCATION Highest level of education the opposing party has attained __________________________ List any certificates or degrees that the opposing party holds _________________________ CLIENT CONTACT - 6 - 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? _________________________ 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 (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 drycleaning --------- $ __________ (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 --------- $ __________ - 7 - (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 --------- $ __________ (2) Supplies and hardware --------- $ __________ (3) Furniture and appliance purchases $ __________ (4) Yard service --------- $ __________ (5) Assessments --------- $ __________ (6) Shrubbery and flowers --------- $ __________ (7) Garbage removal --------- $ __________ (t) Additional information __________ - - $ __________ re: Debts and expenses __________ -- $ __________ TOTAL: --------- $ __________________ - 8 - MONTHLY INCOME NOTE: To arrive at monthly income if received weekly, multiply weekly income by 52 and divide by 12; if received bi-weekly, 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 --------- $_____________ Social security --------- $_____________ Veterans' Administration benefits --------- $_____________ Unemployment compensation --------- $_____________ Other: _______________ --------- $_____________ _______________ --------- $_____________ Total other income --------- $_____________ Total monthly income --------- $_____________ - 9 - 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. - 10 - 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 Institution - - - - (specify) (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 ______________________________ --------- $ $ ______________________________ --------- $ $ ______________________________ --------- $ $ ______________________________ --------- $ $ - 12 - Use additional sheets as needed to complete this section. Secured Debts Creditor Balance ------- Payment Description/Security Interest ____________________ $ --------- $ ____________________ ____________________ $ --------- $ ____________________ ____________________ $ --------- $ ____________________ ____________________ $ --------- $ ____________________ 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? Yes No If so, state which party, whose estate and approximate amount to be received Are you the beneficiary under any trust? Yes No If you are the beneficiary under a trust, please state by whom was the Trust established, the approximate value of your share of the Trust, and the annual income derived therefrom. - 13 - REAL PROPERTY Homestead Address: ________________________________________ Do you have a Certificate of Title to your home? Yes No 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 $ Amount of insurance premium $ included in monthly payment $ 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. _________________________ - 14 - 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 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 - 15 - 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: $ 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 ________________________________________ - 16 - Type of business ________________________________________ % of ownership % Years established Last year Schedule C filed Value (est.) $ Valuation method ________________________________________ Is there a balance sheet for the business? Yes No 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? Yes No If so, who prepared it? ________________________________________ Corporations Name Business location ________________________________________ Type of business ________________________________________ - 17 - % of ownership % Years established Last year corporate tax return filed Value (est.) $ Valuation method ______________________________ Is this a Subchapter S corporation? Yes No What is the fiscal year of the corporation? ____________________ - 18 - 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. - 19 -