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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