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Client Information Questionnaire Post-Parentage 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 ________ ________ ________ ________ 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 you can be reached ________ ________ ________ - 1 - Telephone Number ________ ________ ________ Relationship to you ________ ________ ________ ________ 16. ADDRESS FOR MAIL IF DIFFERENT THAN HOME ADDRESS _____ _ FORMTEX T _ __ FORMTE XT _______ _ FORMTE XT _______ _ FORMTE XT ________ _____ _ ________ ________ 17. All children born to or adopted by you, if any: Child's Child's Child's Child's Name Birth date Age 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? ________ ________ ________ ________ ________ ________ ________ - 2 - ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ 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 ________ 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 ________ - 3 - 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 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 ________ - 4 - YOUR CURRENT FINANCIAL INFORMATION : Fair Market Assets Value Encumbrances ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ 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 ________ ________ ________ ________ __ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Balance Monthly Reason Debt Creditors Due Payments Incurred ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ EX-SPOUSE'S CURRENT PERSONAL INFORMATION (IF KNOWN) : - 5 - 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 ________ ________ Birth date ________ ________ ________ 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 Child's Child's Child's Name Birth date Age Mother/Father ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ - 6 - EX-SPOUSE'S CURRENT EMPLOYMENT INFORMATION (IF KNOWN) : 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. 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.) ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ - 7 - 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 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) : Fair Market Assets Value Encumbrances ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ 1. What are your current approximate total monthly living expenses? ________ ________ 2. Have you included expenses for any other person(s) in this total? ________ Whose? - 8 - ________ ________ ________ ________ ________ ________ ________ 3. Identify and explain any significant increase or decrease in your monthly expenses since the divorce ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Balance Monthly Reason Debt Creditors Due Payments Incurred ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ DISSOLUTION INFORMATION - FORMER MARRIAGE : 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 - 9. Assets, including any homestead or other real estate, awarded to you by the Judgment and Decree: Value at date Encumbrances at of Judgment date of Judgment Assets and Decree and Decree ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ 10. Assets, including any homestead or other real estate, awarded to your ex-spouse by the Judgment and Decree: Value at date Encumbrances at of Judgment date of Judgment Assets and Decree and Decree ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ 11. Debts Owed at Time of Dissolution: Creditor Balance Due at Dissolution Monthly Payment Current Balance Who Was Required To Pay Debt - 10 - 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? ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ 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? ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ - 11 - ________ ________ ________ ________ ________ ________ ________ 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. - 12 -

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