Fill and Sign the Minnesota Client 497312366 Form

Client Information Questionnaire Post-Decree So that we will be able to answer your questions and handle your case in a prompt and efficient manner, it is important that you attempt to answer the following questions fully and accurately. If you need additional space for an answer, you may use the back of a page. The completed questionnaire will be kept confidential and will remain in our possession. Please print your answers. Date: _______________ Referred by: _______________ YOUR CURRENT PERSONAL INFORMATION : 1. Full Name ________________________________________ 2. All previous names you have ever used ________________________________________ 3. Present Street Address ________________________________________ City County ________ State ____ Zip ________ 4. Home Phone ________ Business Phone ________ Pager __________ Cellular Phone __________ 5. Social Security Number Social Security No. 6. Length of residence in Minnesota _______________ 7. Age       Birthdate __________ 8. Religion Race _______________ 9. Highest Level of Education __________ Year Completed ________ 10. Present Health ______________________________ 11. Physician or Clinic ______________________________ 12. Are you presently in the military service? _________________________ 13. Name of person [other than your spouse] who would be most likely to always know where - 1 - you can be reached _________________________ Telephone Number _______________ Relationship to you ______________________________ 16. ADDRESS FOR MAIL IF DIFFERENT THAN HOME ADDRESS ________________________________________ 17. All children born to or adopted by you, if any: Child’s Name Child’s Birthdate Age Child’s Mother/Father ____________ ____________       ____________ ____________ ____________       ____________ ____________ ____________       ____________ ____________ ____________       ____________ 18. How was custody of the minor children awarded? _______________ 19. What visitation was provided? _______________ 20. What are the current custody/visitation arrangements? _______________ 21. Who claims the tax exemptions for the minor children? _______________ 22. Who provides medical insurance for the children? ________________________________________ 23. Are the children beneficiaries of any life insurance policies? ________________________________________ 24. Maintenance and support payments received by you : Maintenance $ ________ per ________ from ________ Child Support $ ________ per ________ from ________ 25. Maintenance and support payments paid by you : Maintenance $ ________ per ________ from ________ Child Support $ ________ per ________ from ________ - 2 - YOUR CURRENT EMPLOYMENT INFORMATION : 1. Employer ________________________________________ 2. Address ________________________________________ 3. Occupation ________________________________________ 4. Length of time with this Employer ______________________________ 5. How often are you regularly paid: Weekly Every two weeks Twice per month Monthly 6. Present Gross Earnings $ ________ Per ________ 7. Present Net Earnings $ ________ Per ________ 8. Exemptions Claimed: Federal M- ________ State M- ________ S - ________ S- ________ 9. Deductions from your paycheck: Federal $ ________ Per ________ State $ ________ Per ________ FICA $ ________ Per ________ Medical/Dental $ ________ Per ________ Other (Specify) $ ________ Per ________ 10. Describe the type and amount of other income (overtime, bonuses, commissions, other employment) ________ ________ ________ ________ ________ ________ 11. Describe all other employment benefits (car, car allowance, meals, memberships, etc.) ________________________________________ 12. Detail your prior work experience (what, when and where) 13. Do you receive, or expect to receive, any of the following as income: Public Assistance Yes No Social Security Benefits for Yourself Yes No Social Security Benefits for Child(ren) Yes No - 3 - Unemployment Compensation Yes No Worker's Compensation Yes No Rental Income Yes No Other Income Yes No If Yes, What: ________________________________________ 14. If you have remarried, is your present spouse employed? ________ Approximate gross earnings of present spouse $ ________ per ________ Approximate net earnings of present spouse $ ________ per ________ YOUR CURRENT FINANCIAL INFORMATION : Assets Encumbrances Fair Market V alue ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ 1. What are your current approximate total monthly living expenses? ________ ________ 2. Have you included expenses for any other person(s) in this total? ________ Whose? ________________________________________ 3. Identify and explain any significant increase or decrease in your monthly expenses since the divorce ________________________________________ Creditors Balance Due Monthly Payments Reason Debt Incurred ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ EX-SPOUSE'S CURRENT PERSONAL INFORMATION (IF KNOWN) : - 4 - 1. Full Name _________________________ 2. All previous names you have ever used ______________________________ 3. Present Street Address _________________________ City County ________ State ____ Zip ________ 4. Home Phone ________ Business Phone ________ Pager ________ Cellular Phone ________ 5. Social Security Number _______________ 6. Length of residence in Minnesota __________ 7. Age ________ Birthdate _______________ 8. Religion _______________ Race _______________ 9. Highest Level of Education ________ Year Completed ________ 10. Present Health ______________________________ 11. Physician or Clinic ______________________________ 12. Is your ex-spouse in the military? ________ 13. Date of remarriage of ex-spouse, if any: _______________ 14. Name of ex-spouse's current spouse, if any: _______________ 15. All children, other than your children , born to or adopted by ex-spouse, if any: Child’s Name Child’s Birthdate Age Child’s Mother/Father ____________ ____________       ____________ ____________ ____________       ____________ ____________ ____________       ____________ ____________ ____________       ____________ EX-SPOUSE'S CURRENT EMPLOYMENT INFORMATION (IF KNOWN) : - 5 - 1. Employer ______________________________ 2. Address ______________________________ 3. Occupation ______________________________ 4. Length of time with this Employer ______________________________ 5. How often are you regularly paid: Weekly Every two weeks Twice per month Monthly 6. Present Gross Earnings $ ________ Per ________ 7. Present Net Earnings $ ________ Per ________ 8. Exemptions Claimed: Federal M- ________ State M- ________ S- ________ S- ________ 9. Deductions from your paycheck: Federal $ ________ Per ________ State $ ________ Per ________ FICA $ ________ Per ________ Medical/Dental $ ________ Per ________ Other (Specify) $ ________ Per ________ 10. Describe the type and amount of other income (overtime, bonuses, commissions, other employment) ________________________________________ 11. Describe all other employment benefits (car, car allowance, meals, memberships, etc.) ________________________________________ 12. Detail your prior work experience (what, when and where) 13. Do you receive, or expect to receive, any of the following as income: Public Assistance Yes No Social Security Benefits for Yourself Yes No Social Security Benefits for Child(ren) Yes No Unemployment Compensation Yes No Worker's Compensation Yes No - 6 - Rental Income Yes No Other Income Yes No If Yes, What: ________________________________________ 14. If you have remarried, is your present spouse employed? ________ Approximate gross earnings of present spouse $ ________ per ________ Approximate net earnings of present spouse $ ________ per ________ EX-SPOUSE'S CURRENT FINANCIAL INFORMATION (IF KNOWN) : Assets Encumbrances Fair Market V alue ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ 1. What are your current approximate total monthly living expenses? $ ___________ 2. Have you included expenses for any other person(s) in this total? ________ Whose? ________________________________________ 3. Identify and explain any significant increase or decrease in your monthly expenses since the divorce ________________________________________ Creditors Balance Due Monthly Payments Reason Debt Incurred ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ DISSOLUTION INFORMATION - FORMER MARRIAGE : - 7 - 1. Date of Dissolution _______________ 2. Location of Dissolution: City ________ County ________ State ___ 3. Who initiated the dissolution proceedings? ____________________ 4. Did you settle your case or go to trial? ________________________________________ 5. Describe any court proceedings since the dissolution was granted ________________________________________ ________________________________________ 6. Do you have copies of any of the dissolution or post- dissolution documents? ________________________________________ 7. Name of the attorney that represented you ________________________________________ 8. Name of your ex-spouse's attorney ________________________________________ 9. Assets, including any homestead or other real estate, awarded to you by the Judgment and Decree: Assets Encumbrances Fair Market V alue ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ 10. Assets, including any homestead or other real estate, awarded to your ex-spouse by the Judgment and Decree: Assets Value at Date of Judgment and Decree Encumbrances at Date of Judgment and Decree ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ - 8 - ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ 11. Debts Owed at Time of Dissolution: Creditor Balance Due at Dissolution Monthly Payment Current Balance Who Was Required To Pay Debt __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 12. Your Income at Time of Dissolution: Gross income: $ ________ per ________ Net income: $ ________ per ________ 13. Ex-spouse's income at Time of Dissolution: Gross income: $ ________ per ________ Net income: $ ________ per ________ 14. Expenses at Time of Dissolution: a. Did you or your ex-spouse prepare any monthly budgets during the dissolution proceeding? ______________________________ b. Total monthly expenses claimed by you: $ ___________ c. Total monthly expenses claimed by your ex-spouse $ ___________ MISCELLANEOUS : 1. Are you or your current spouse named as a party in any pending lawsuit, or have you ever filed for bankruptcy? ______________________________ 2. Is your ex-spouse named as a party in any pending lawsuit, or has your ex-spouse ever filed for bankruptcy? ________________________________________ - 9 - 3. If you and/or your ex-spouse are not abiding by the terms of the Judgment and Decree (or subsequent Orders), describe the variation. ________________________________________ 4. Why are you consulting with me today? ________________________________________ I acknowledge that I am responsible for payment of the initial consultation fee at the rate of $ ________ per hour at the time of the initial consultation. Date: _________________ _________________________________ A COPY OF THE JUDGMENT AND DECREE AND ANY OTHER COURT DOCUMENTS CONCERNING YOUR CASE SHOULD BE PROVIDED AS SOON AS POSSIBLE. - 10 -