POST-DECREE MODIFICATION QUESTIONNAIRE
Support/Maintenance
Custody
Visitation
Please fill out this form as completely as possible. If a section of information does not
apply to you or your former spouse, please check "No" or "not applicable" at the beginning of the
section. If some questions in an otherwise inapplicable section are relevant, please just complete
the requested information. All information is highly confidential, protected by the attorney/client
privilege.
Please read the entire questionnaire first for an idea of the necessary information you shall
have to collect to work through the questions in an efficient way. The more time and attention that
you put into the completion of the necessary information, the less time the attorney and the legal
assistant will need to spend in obtaining such data for you and from you. This effort on your part
could result in a substantial reduction in the fees charged for expensive professional services. Do
not panic if you just do not know the answers to specific questions. At our first conference, we will
work through the entire questionnaire, structuring the information and legal concepts directly to
your particular situation. Some of the information might be under the control of your former
spouse. That information, if vital to your representation and best interests in this post decree
proceeding, can be obtained through a process known as discovery in which specific questions
would be directed to your former spouse's attorney for completion of the blank areas.
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1. BACKGROUND COURT INFORMATION
Names of parties as they appear on the last court order or on the Judgment and Decree:
Petitioner
Respondent
Date of entry of divorce decree County of divorce Court file no.
Have any additional orders been entered? Yes No
Identify the issues and date of order:
Please bring copies of:
* Findings of fact, conclusions of law, order for judgment, Judgment and decree, and
* All court orders entered after the divorce decree.
2. CLIENT DATA
Your full name
(first) (middle) (last)
Birth date Present age
Address Telephone: (Home) (Work)
Is this a family residence? Yes No
Type of residence Homestead Rental property
Number of bedrooms:
Presently occupied by: wife husband children
Please provide a fairly permanent contact address (parent, sibling) who would know how to find
you, if necessary, in five years.
Name and relationship Address
Telephone
Have you remarried? Yes No (Go to Section 3)
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Name of present spouse? Date of present marriage
Does your present spouse work? Yes No
Are there stepchildren presently residing within your home? Yes No
Is your present spouse a noncustodial parent of other children who do not reside within your home?
Yes No
How did you obtain my name?
Personal referral by
Yellow pages ad
Other (please specify)
3. FORMER SPOUSE'S DATA
Former spouse's full name
(first) (middle) (last)
Birth date Present age
Address Telephone (Home) (Work)
Has former spouse remarried? Yes No
Name of present spouse Date of present marriage
Does the present spouse work? Yes No
Are there stepchildren in your former spouse's present home? Yes No
Does your former spouse have an attorney representing him/her in this post dissolution of marriage
action? Yes No
Name
Address
Telephone
Is this the same attorney who represented him/her during the divorce? Yes No
4. CHILDREN CUSTODY AND VISITATION
There were children born to, or adopted during, the marriage that is the subject of this post
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decree action.
Name (first, middle, last) Birth date Age
Who is the custodian of the children listed above?
Is custody or visitation at issue? Yes Not applicable If no, go to Section 5.
Considerations in Bringing a Post decree Action for Change of Custody or Visitation
It is necessary to establish in an affidavit the change in circumstances of the parties from the
time the last order on custody or visitation was entered that makes a change in custody or visitation
vital to the children's best interests. Basically, that means a showing must be made to the court that
maintaining the children in the present home threatens their academic, physical, spiritual,
intellectual or emotional growth and development. Specific conditions that pose such a detrimental
impact on the children must be detailed. If the present custodian is denying, interfering with, or
limiting the access of the visitation of the noncustodian with the children in violation of court order
or past practices of visitation of the parties, grounds may exist for a change. The burden of proof is
on the party who desires a change to establish such need for the change in custody and visitation.
Please write up the chronology of events and problems that have occurred since the date of
entry of the last order that make a change necessary in the custody or visitation provisions of the
existing order. Use a separate sheet of paper. This information shall provide the basis of the
supportive affidavit to be submitted to the court at the initial hearing on the motions for a change in
the custody or visitation provisions of the present order.
You must be aware that motions for a change of custody or visitation are routinely opposed
by the former spouse with cross-motions for collection of all unpaid support by reduction to a
judgment against you or for an increase in the existing level of support or change in the financial
obligations established under the divorce decree. This would almost certainly include a request for
the implementation of a cost-of-living adjustment to the existing child support obligation every two
years, a motion that the court must grant under new changes in the law, or in cases of delinquent
support payments, a request for an automatic deduction from your paycheck of the court-ordered
support.
Do you desire custody of the children born to your last marriage? Yes No
If yes, list children you desire custody of and explain why.
Do you expect your former spouse to make an issue over who should have custody of the children?
Yes No Why?
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What type of visitation would be reasonable for the noncustodian?
The children presently reside with
Address
Has there been past involvement with:
court services? a guardian ad litem?
a counselor? child protection?
Bring court services reports and evaluations if available.
Bring counselors records or reports on problems, if available.
Would you consider using the court services or private mediation services to resolve the problems
for which you are seeking legal help? Yes No
Relocation of the Custodian with the Minor Children
Is there an intended relocation of the custodian out of the state of Minnesota with the minor
children? Yes No
Do you anticipate objections or intend to object to such a move? Yes No
Note that the existing level of support may be raised to cover the increased transportation expense
to enable visitation with the non-relocating parent. Please answer the following questions in detail.
Why is the custodian intending to relocate to another state?
Could a showing be made that the child(ren) are integrated into the home of the custodian?
the non-custodian? Explain.
Could a showing be made that it is in the best interests of the child(ren) to be allowed to move?
Yes No Explain.
Could a showing be made that the intent of the move is to deprive the non-custodian of visitation or
a relationship with the child(ren). Detail past episodes to substantiate.
5. CHILDREN FROM A PRIOR MARRIAGE Not applicable
Client's Children
Client has children from a previous marriage.
Other parent's complete name
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Child(ren)'s Name(s) Birth date Age
Who is the custodian of these children?
Where, and with whom do these children live? Please specify.
Relationship
Name
Address
Date of entry of prior divorce decree of parents of children from prior marriage
County and state of divorce ,
Is child support ordered for these children? Yes No
Payable by To Amount ordered per month per child $
Total monthly support obligation $
Other forms of support ordered (medical and dental insurance or other
Date of such court order
Are there delinquencies in support ordered payments or other noncompliance with any of the terms
of the court order? Yes No Explain
Formers Spouse's Children
The former wife/husband has child(ren) of a previous marriage.
Other parent's complete name
Child(ren)'s Name(s) Birth date Age
Who is the custodian of these children?
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Where, and with whom do these children live? Please specify.
Relationship
Name
Address
Date of entry of prior divorce decree of parents of children from prior marriage
County and state of divorce ,
Is child support ordered for these children? Yes No
Payable by To Amount ordered per month per child $
Total monthly support obligation $
Other forms of support ordered (medical and dental insurance or other)
Date of such court order
Are there delinquencies in support ordered payments or other noncompliance with any of the terms
of the court order? Yes No Explain
6. ILLEGITIMATE CHILDREN Not applicable
Do you or your former spouse have any illegitimate children? Yes No
Name(s) Birth date Age
Has paternity been established? Yes No If yes, please initial such children's names with a P .
How
Has an order of paternity been entered? Yes No
Date County State
Is there an affidavit of paternity filed with the department of vital statistics? Yes No
If yes, please state the date and the state in which it is filed.
What is the monthly child support obligation for these children?
$ paid or received.
Are there any child support arrearages? Yes No Amount $
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Is welfare involved? Yes No
Any separate support proceedings with court orders? Yes No
If yes, please bring copies of such documents.
7. JUVENILE COURT JURISDICTION Not applicable
Are any of the children of this past marriage, a prior marriage or either party's present marriage now
involved in any juvenile court proceeding? Yes No. If yes, please state the name of the
child, names of the parents and in what county the proceeding is located:
Name Parents County
Reason for proceeding
Are any of the children out of the home in:
foster care chemical dependency treatment
in patient halfway house
other. Please specify
Is there any court-ordered support obligation for the children's placement out of the home?
Yes No If so, what is the monthly support figure? $
Are all amounts current? Yes No State existing arrearages, if any. $
8. EXISTING SUPPORT ORDERS
If there is back support owed , the court will enter an order that support money be
deducted directly from the paycheck of the person responsible for payment of such support. This
obviously is not very effective with self-employed persons, but it does give a degree of regularity
and assurance if the employer is sending out the support money when the employee/obligor is paid.
To receive support in this manner, the person entitled to support must sign up with the county
support and collections department on the title IV-D program so that the employer payment of
support can be made directly to the county for transmittal to the custodian. You should also know
that the county attorney will represent you without charge to obtain back support by judgment and
establish a wage-withholding deduction from the former spouse's paycheck. It is important to be
accurate in the computation of back support owed to you. Nothing is more damaging to the
credibility of a person seeking contempt of court and a wage assignment for unpaid back support
than to have the figures thrown into chaos and dispute by cancelled checks not included in the
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computation. As a general practice, support payments should always be deposited in a bank within
two days of receipt in a deposit that is limited to that support payment alone and is clearly marked
in the check register and deposit slip as a support payment for a specified period.
If you are seeking an increase in the support obligation you receive or you are seeking
to reduce the support you pay , you must show a material change in circumstances that justifies
such an increase or decrease. To do this, you must establish what the financial circumstances of
each person were at the time of the entry of the last support order and the changes since then.
Remarriage of either party can constitute a material change in circumstances through a change in
living expenses. The income of a new spouse is not to be considered, by law. Financial
information becomes vital in such a comparison of past and present financial circumstances.
Please note that motions for a change in the support obligation are routinely countered by
cross-motions for a change in custody or visitation established under the divorce decree. The
information relative to the custody and visitation section should be completed, if such motions can
be reasonably anticipated.
Has support been ordered? Yes No Is support current? Yes No
child support $ per (week/month).
spousal maintenance (alimony) $ per (week/month).
Please compute the arrearages (unpaid support) specifying the date such payment was to begin and
all unpaid amounts by month owed. Credit all partial payments in each month. Construct a chart,
particularly if the payment history has been extremely sporadic or irregular.
Example : On October 20, 1979, the court ordered child support of $125 per month.
Month* Paid Owed
October 1992 $ 00.00 $ 44.35**
November 1992 115.00 10.00
December 1992 75.00 50.00
Total arrearages: $104.35
* Months since the last order.
**$125.00 : 31 = $4.03 x 11 = $44.35. (Prorate the days in the month from the effective date of the
order by dividing the amount due by the number of days in that month and multiply that figure by
the balance of the days left in the month.)
Total arrearages due and owing $ child support
$ spousal maintenance
Does the divorce decree or existing support order set out your financial circumstances at the time
your current support level was established? Yes No
Please bring the most current support order or decree.
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Was there a temporary hearing during your divorce in which the temporary order or temporary
application for relief set out the financial circumstances at the time of the hearing? Yes No
Please bring such documentation.
This information is necessary to establish the change in circum-stances by direct reference to
information in the court file. Such documents should have been provided to you for your records
by former lawyers or at time of service on you. Otherwise, you should be able to obtain copies of
your file from your prior attorney or at the courthouse.
9. CLIENT'S WELFARE OR UNEMPLOYMENT INCOME Not applicable
At Time Existing Support Order Entered
Did you receive welfare? Yes No.
If so, what kind of welfare? AFDC AFDC-unemployed spouse food stamps
Agency/agencies
Your Case Worker
Telephone No. County
Did you receive unemployment compensation? Yes No
If yes, what was the amount of each check? $
How often received?
When did your unemployment claim end?
At the Present Time
Have you applied, or do you intend to apply, for any form of welfare? Yes No.
If yes, please complete any relevant information below known to you at this time. If any of
the information following applies to your present spouse's present circumstances because of
unemployment compensation, AFDC for unemployed parent, eligibility for food stamps or
any other reason, please supply the information.
Do you receive welfare? Yes No.
If so, what kind of welfare? AFDC AFDC-unemployed spouse food stamps
Agency/agencies
Your Case Worker
Telephone No. County
Do you receive unemployment compensation? Yes No
If yes, what is the amount of each check? $ How often received?
When is your unemployment claim end?
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10. FORMER SPOUSE'S WELFARE OR UNEMPLOYMENT INCOME
Not applicable
At Time Existing Support Order Entered
Did your former spouse receive welfare? Yes No.
If so, what kind of welfare? AFDC AFDC-unemployed spouse food stamps
Agency/agencies
Your Case Worker
Telephone No. County
Did your former spouse receive unemployment compensation? Yes No
If yes, what was the amount of each check? $ How often received?
When did the unemployment claim end?
Present Time
Has your former spouse applied, or do you know if s/he intends to apply, for any form of welfare?
Yes No.
If yes, please complete any relevant information known below. If any of the following information
is applicable to the present spouse of your former spouse, please fill in the known information as to
him or her. Remember, discovery will be used to get the concrete details of monies received in that
household.
Does your former spouse receive welfare? Yes No.
If so, what kind of welfare? AFDC AFDC-unemployed spouse food stamps
Agency/agencies
Your Case Worker
Telephone No. County
Does your former spouse receive unemployment compensation? Yes No
If yes, what is the amount of each check? $ How often received?
When does the unemployment claim end?
Has your former spouse been off work for any amount of time due to:
medical strike
disability other?
11. EMPLOYMENT OF CLIENT
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Employment at Time Existing Support Order Entered
Your occupation Your employer
Address Telephone
How long had you been at the above employment?
full time for years
part time for years
How were you paid?
weekly semimonthly (twice a month)
every two weeks other, (specify, particularly if self-employed)
Salary per paycheck
$ gross $ net take home
$ hourly rate
Did you claim withholding on your earnings as
married or single? How many exemptions? state federal
Please bring with you:
* Copies of past paycheck stubs at the time support set by order
* Copies of last joint tax return filed between client and former spouse
* Copies of tax return filed for the year support was set by decree.
List other fringe benefits available to you through such past employment:
medical coverage dependent life insurance
dental coverage disability
dependent medical coverage reimbursement for travel expenses
dependent dental coverage other, specify
life insurance
Does the existing support order or judgment and decree make provision for maintaining any of the
following on behalf of, or for the protection of, the minor children of this marriage?
medical dental life insurance protection
Whose responsibility is such insurance obligation? Who pays the premium expense?
Who pays deductible and uninsured amounts? (example: 50/50 split)
Present Employment
Are you presently employed? Yes No If yes, specify the following:
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Employer: Occupation?
Address: How long have you been employed at this job?
What is your Gross income per $
1. Gross income per $
2. Statutory Deductions:
Federal income tax $
State withholding $
Social Security (FICA) $
Pension deduction $
Union dues $
Dependent health/hospitalization coverage $
Dental coverage $
3. Subtotal of Stat. Deductions $
4. Net income (Line 1 minus Line 3) $
5. Other paycheck deductions: Specify $
$
6. Subtotal Other Deductions $
7. Net take home pay (Line 4 - Line 6) $
Tax withholding above are based on married-single with # deductions
Do you receive any other compensation, benefits, or perks from your employer such as:
Commission: Yes No When paid? How is it calculated:
Profit sharing: Yes No When paid? Amount: $
Expense account: Yes No When paid?
What does expense account cover?:
Bonus: Yes No When paid? How is bonus calculated?:
Car allowance: Yes No
How much is paid, what does it cover and how often is it paid?:
Are receipts needed?: Yes No
ESOP (Employee Stock Option Plan): Yes No Describe:
Stock options: Yes No
Describe options and any special requirements to exercise:
Board of directors fees: Yes No How much is paid and how often?
Other (Describe in detail identifying the benefit/perk, the amount/value and how often received) :
Other income:
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Public assistance (AFDC/GA) $
Social Security benefits for party or child(ren) $
Unemployment/workers comp. $
Interest income per $
Dividend income per $
Gross rental income $
Other income $
What is your highest level of education (Check One):
High School
College: 1 yr. 2 yrs. 3 yrs. 4 yrs.
Graduate school: Masters Ph.D. Other (Describe)
Medical School (Describe Degree):
Law School (Describe Degree):
12. EMPLOYMENT OF CLIENT'S PRESENT SPOUSE Not applicable/None
(This is not for use in court)
Is your current spouse presently employed? Yes No If yes, specify the following:
Employer: What is your current spouse's Occupation?
Address:
How long has your current spouse been employed at this job?
1. Gross income per $
2. Statutory Deductions:
Federal income tax $
State withholding $
Social Security (FICA) $
Pension deduction $
Union dues $
Dependent health/hospitalization coverage $
Dental coverage $
3. Subtotal of Stat. Deductions $
4. Net income (Line 1 minus Line 3) $
5. Other paycheck deductions: Specify $
$
6. Subtotal Other Deductions $
7. Net take home pay (Line 4 - Line 6) $
Tax withholding above are based on married-single with # deductions
Does your current spouse receive any other compensation, benefits, or perks from his/her employer
such as:
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Commission: Yes No When Paid? How is it calculated:
Profit sharing Yes No When paid? Amount: $
Expense account: Yes No When paid?
What does expense account cover
Bonus: Yes No When paid? How is bonus calculated?
Car allowance: Yes No
How much is paid, what does it cover and how often is it paid?
Are receipts needed? Yes No
ESOP (Employee Stock Option Plan): Yes No Describe:
Stock Options: Yes No Describe options and any special Requirements to exercise
Other (Describe in detail identifying the benefit/perk, the amount/value and how often received) :
Other income:
Public assistance (AFDC/GA) $
Social Security benefits for party or child(ren) $
Unemployment/workers comp. $
Interest income per $
Dividend income per $
Gross rental income $
Other income $
What is your current spouse's highest level of education (Check one):
High school
College: 1 Yr. 2 Yrs. 3 Yrs. 4 Yrs.
Graduate school: Masters Ph.D. Other (Describe)
Medical School (Describe Degree)
Law School (Describe Degree)
13. FORMER SPOUSE'S EMPLOYMENT
Employment at Time Existing Support Order Entered
Was your former spouse employed? Yes No If yes, specify the following:
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Employer: What was his/her occupation?
Address:
How long had s/he been employed at this job?
1. Gross income per $
2. Statutory Deductions:
Federal income tax $
State withholding $
Social Security (FICA) $
Pension deduction $
Union dues $
Dependent health/hospitalization coverage $
Dental coverage $
3. Subtotal of Stat. Deductions $
4. Net income (Line 1 minus Line 3) $
5. Other paycheck deductions: Specify $
$
6. Subtotal Other Deductions $
7. Net take home pay (Line 4 - Line 6) $
Tax withholding above are based on married-single with # deductions
Did s/he receive any other compensation, benefits, or Perks/Perks from his/her employer such as:
Commission: Yes No When Paid? How is it calculated:
Profit sharing Yes No When paid? Amount:
Expense account: Yes No When paid?
What does expense account cover
Bonus: Yes No When paid? How is bonus calculated?
Car allowance: Yes No How much is paid, what does it cover and how often is it paid?:
Are receipts needed?:
ESOP (Employee Stock Option Plan): Yes No Describe:
Stock Options: Yes No Describe options and any special Requirements to exercise
Other (Describe in detail identifying the benefit/perk, the amount/value and how often received) :
Other income:
Public assistance (AFDC/GA) $
Social Security benefits for party or child(ren) $
Unemployment/workers comp. $
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Interest income per $
Dividend income per $
Gross rental income $
Other income $
What is your current spouse's highest level of education (Check one):
High school
College: 1 Yr. 2 Yrs. 3 Yrs. 4 Yrs.
Graduate school: Masters Ph.D. Other (Describe)
Medical School (Describe Degree)
Law School (Describe Degree)
Present Employment
Is your former spouse employed? Yes No If yes, specify the following:
Employer: What is his/her occupation?
Address: How long has s/he been employed at this job?
Gross income per $
1. Gross income per $
2. Statutory Deductions:
Federal income tax $
State withholding $
Social Security (FICA) $
Pension deduction $
Union dues $
Dependent health/hospitalization coverage $
Dental coverage $
3. Subtotal of Stat. Deductions $
4. Net income (Line 1 minus Line 3) $
5. Other paycheck deductions: Specify $
$
6. Subtotal Other Deductions $
7. Net take home pay (Line 4 - Line 6) $
Tax withholding above are based on married-single with # deductions
Did s/he receive any other compensation, benefits, or Perks/Perks from his/her employer such as:
Commission: Yes No When Paid? How is it calculated:
Profit sharing Yes: No When paid? Amount:
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Expense account: Yes No When paid? What does expense account cover?
Bonus: Yes No When paid? How is bonus calculated?:
Car allowance: Yes No How much is paid, what does it cover and how often is it
paid?: Are receipts needed?:
ESOP (Employee Stock Option Plan): Yes No Describe:
Stock Options: Yes No Describe options and any special Requirements to exercise
Other (Describe in detail identifying the benefit/perk, the amount/value and how often received) :
Other income:
Public assistance (AFDC/GA) $
Social Security benefits for party or child(ren) $
Unemployment/workers comp. $
Interest income per $
Dividend income per $
Gross rental income $
Other income $
What is your current spouse's highest level of education (Check one):
High school
College: 1 Yr. 2 Yrs. 3 Yrs. 4 Yrs.
Graduate school: Masters Ph.D. Other (Describe)
Medical School (Describe Degree)
Law School (Describe Degree)
14. EXISTING MONEY ACCOUNTS
If you need more room for entries, draw a line down the middle of the column and double up the
entries. If you own treasury notes, certificates of deposit, stocks, bonds and other forms of
investment, please describe them in detail.
Name of bank (or broker/treasury note holder as applicable)
Authorized users (in whose name(s) Amount in account $
Account number Type of Account
Name of bank (or broker/treasury note holder as applicable)
Authorized users (in whose name(s) Amount in account $
Account number Type of Account
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Name of bank (or broker/treasury note holder as applicable)
Authorized users (in whose name(s) Amount in account $
Account number Type of Account
Name of bank (or broker/treasury note holder as applicable)
Authorized users (in whose name(s) Amount in account $
Account number Type of Account
Name of bank (or broker/treasury note holder as applicable)
Authorized users (in whose name(s) Amount in account $
Account number Type of Account
15. REAL PROPERTY
There is space to identify two properties. If there are more than two properties, please copy
this section before you complete it in order to provide us with information on each property.
Type of property: Homestead Recreational Investment
Address: In whose name is the property held?:
Legal description (from deed, abstract, or certificate of title- Not Tax Statement
Is the realty abstract or Torrens property? If Torrens property, provide certificate of title
no.
Date purchased: Purchase price:
Down payment: Source of down payment:
Name of first mortgage holder: Loan No.: Current balance of mortgage: $
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Name of second mortgage holder:
Current balance of mortgage: $ Loan No.:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Contract for deed balance $ Owners of contract for deed:
Address:
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How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Home equity loan holder (if other than second mortgage):
Current balance: $ Loan No.:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Home improvement loan holder (if other than second mortgage):
Current balance: $ Loan No.:
How often are payments due: Amount of payment $
Are payments current? Yes No If yes, how many payments
Other encumbrances, if any:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Your estimated market value: $ Tax assessor's Value: $ Approximate equity: $
Are real estate taxes paid separately from the mortgage: Yes No
If yes, how much are the real estate taxes per year:
Are the real estate taxes current?: Yes No
=================================================================
Type of property: Homestead Recreational Investment
Address: In whose name is the property held?:
Legal description (from deed, abstract, or certificate of title- Not Tax Statement
Is the realty abstract or Torrens property? If Torrens property, provide certificate of title
no.
Date purchased: Purchase price:
Down payment: Source of down payment:
Name of first mortgage holder: Loan No.: Current balance of mortgage: $
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Name of second mortgage holder:
Current balance of mortgage: $ Loan No.:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
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Contract for deed balance $ Owners of contract for deed:
Address:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Home equity loan holder (if other than second mortgage):
Current balance: $ Loan No.:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Home improvement loan holder (if other than second mortgage):
Current balance: $ Loan No.:
How often are payments due: Amount of payment $
Are payments current? Yes No If yes, how many payments
Other encumbrances, if any:
How often are payments due: Amount of payment $
Are payments current?: Yes No If yes, how many payments
Your estimated market value: $ Tax assessor's Value: $ Approximate equity: $
Are real estate taxes paid separately from the mortgage: Yes No
If yes, how much are the real estate taxes per year:
Are the real estate taxes current?: Yes No
16. INDEBTEDNESS
What is your present indebtedness picture? List loans, charge accounts or installment purchases
and other debts, including those to individuals or relatives.
List bills that existed at time of divorce, as opposed to bills incurred by you individually after
the divorce was final. Please indicate by S or U whether the debt is secured or unsecured.
Secured debts have property pledged that could be repossessed or taken back by the creditor if
payments are not made.
Marital Debts
Creditor Balance Current Monthly
Name Acct. No. at Divorce Balance Payment S or U
Who was ordered to pay marital debts in decree?
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Individual indebtedness incurred after the divorce (yours or spouses, please indicate)
Individual Debts Since Divorce
Credit cards -
Identify card type (Visa, AmEx, MasterCard):
Name on the account:
Who is authorized to use the card:
Primary purpose for which the card is used:
Balance: $ Monthly payment: $
Date of balance:
Are payments current: Yes No
If payments are not current how many payments are in arrears?:
Identify card type (Visa, AmEx, MasterCard):
Name on the account:
Who is authorized to use the card:
Primary purpose for which the card is used:
Balance: $ Monthly payment: $
Date of balance:
Are payments current: Yes No
If payments are not current how many payments are in arrears?:
Identify card type (Visa, AmEx, MasterCard):
Name on the account:
Who is authorized to use the card:
Primary purpose for which the card is used:
Balance: $ Monthly payment: $
Date of balance:
Are payments current: Yes No
If payments are not current how many payments are in arrears?:
Identify card type (Visa, AmEx, MasterCard):
Name on the account:
Who is authorized to use the card:
Primary purpose for which the card is used:
Balance: $ Monthly payment: $
Date of balance:
Are payments current: Yes No
If payments are not current how many payments are in arrears?:
Other debts (Include debts on cars, boats or recreational vehicles):
To whom is the money owed? Purpose of the debt:
How often are payments due: Are payments current? Yes No
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If no, how much is owed: $
Amount of monthly or other payment: $
Is there a promissory or other written loan document? Yes No
Identify any security for the loan:
To whom is the money owed? Purpose of the debt:
How often are payments due: Are payments current? Yes No
If no, how much is owed: $
Amount of monthly or other payment: $
Is there a promissory or other written loan document? Yes No
Identify any security for the loan:
UNPAID TAXES:
Do you and/or your spouse owe any federal or state taxes? Yes No
If yes, state the year and amount of tax owed: $
LITIGATION/LAWSUITS:
Are you or your current spouse or both of you named as parties in any existing lawsuit?
Yes No If yes, Please detail:
Who is the lawyer on the case (name, address, telephone #) , ,
Have you been told when a trial or finalization of the lawsuit might occur? If yes, please
provide whatever information you have:
17. INSURANCE
Do you or your current spouse own any life insurance? Yes No If yes, specify:
Carrier: Owner of policy: Policy No.
On life of: FACE AMOUNT $ Cash value $
Encumbered in the amount of $ Beneficiary(ies):
Carrier: Owner of policy: Policy No.
On life of: FACE AMOUNT $ Cash value $
Encumbered in the amount of $ Beneficiary(ies):
Carrier: Owner of policy: Policy No.
On life of: FACE AMOUNT $ Cash value $
Encumbered in the amount of $ Beneficiary(ies):
MEDICAL INSURANCE
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Do you or your current spouse carry medical and hospitalization insurance? Yes No
If yes, who does it cover?
Is the same provided through your or your current spouse's employer?
What is the name of the carrier?
What is the cost to you or your current spouse ? $ per
Do you or your spouse purchase medical and/or hospitalization insurance privately?
Yes No If yes, give the name of the carrier:
Who does it cover (you, spouse, dependents)?
What is the cost to you or your current spouse ? $ per
DENTAL INSURANCE
Do you or your spouse carry dental insurance? Yes No
If yes, exactly who does it cover?
Is the same provided through your or your spouse's employer?
What is the name of the carrier?
What is the cost to you or your spouse ? $ per
Please asterisk (*) if the type of insurance is available through your employer. Please check
(x) if the type of insurance is available through your spouse's employer.
Please make sure that the amounts indicated above are properly included in your monthly
expenses below.
18. CLIENT'S ESTIMATED MONTHLY EXPENSES
Based on your experience in your present residence, please list your estimated monthly
living expenses for yourself and your children, if they will be in your custody. When using a
weekly amount such as car expenses (weekly gas fill, oil, other), figure out the weekly expense and
multiply it by 4.3. This will give an accurate monthly figure. When using six-month, quarterly, or
annual figures, such as insurance premiums or water bills, please divide the figure by the number of
months to determine the proper monthly rate. If the category does not apply to you, please leave it
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blank. The importance of accuracy and realism in computing living expenses, especially in a post
decree court proceeding, cannot be overemphasized. Please mark any items that you are unsure of
with a ? for discussion with the attorney. The needs of the children are a vital area of focus. Please
note all accounts that are currently delinquent (behind on payments) with a D.
BUDGET
Specify number of minor children included:
Children Client Children Client
Food/Beverage Education
a. Groceries a. Tuition
b. Restaurant b. Transportation
Total $ $ c. Special activities
d. Lunch money
Housing e. Tutoring
a. Mortgage/Rent f. Books/Supplies
b. Property Tax Total $ $
c. Insurance
Total $ $ Insurance (Not deducted by employer)
a. Life
Installment Payments/Other Debts b. Health
a. Maintenance/Repairs c. Accident
b. Second Mortgage. d. Disability
c. Home Equity Loan e. Personal Prop.
Total $ $ f. Personal umbrella
Total $ $
Utilities
a. Electricity Child Care
b. Gas/Fuel Oil a. Transportation
c. Sewer/Water b. Supplies
d. Telephone c. Daycare Ctr.
e. Telephone (long dist.) d. Allowance
f. Garbage e. Summer/day camp
g. Water softener f. Lessons
Total $ $ g. Diaper Service
Total $ $
Furnishings/Operation
a. Services/cleaning Miscellaneous
b. Babysitter a. Child support
c. Furnishings/equipment b. Alimony
Total $ $ c. Income taxes
(not withheld)
Apparel/Upkeep d. Entertainment
a. Clothing/shoes e. Hobbies
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b. Laundry/dry cleaning f. Vacation
Total $ $ g. Gifts
h. Memberships
Transportation i. Newspapers/Mag.
a. Auto install payment j. Haircuts/style
b. Auto insurance k. Cosmetics/toiletry
c. Maintenance/repairs l. Donations/Church
Transportation (cont.) Miscellaneous (cont.)
d. Gasoline m. Pet Care
e. License n. Cable TV
f. Parking o. Employment costs
g. Public transportation p. Savings
h. Replacement reserve q. Retirement
Total $ $ Total $ $
Medical Care (Uninsured) Upcoming Special Expenses (not included above)
a. Doctor a.
b. Dentist b.
c. Orthodontist c.
d. Eye glasses Total $ $
e. Medicine/Drugs
f. Therapy
Total $ $
TOTAL MONTHLY BUDGET (As of ) $
Please bring:
Copies of juvenile court petition
Any existing court orders
Parental agreements or conditions to retain child in home
Support orders, child protection reports or other documents you feel are of importance.
Copies of your tax return for the year in which your divorce was entered and your two most
recent individual returns
Copies of your four most recent paychecks. If year-to-date information is not included,
then bring all paychecks for the year to date or a statement of earnings from your employer
Verification of all other income available to you
Check registers and bank statements for the last twelve months
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Copies of all credit card and monthly debt statements
Copies of all other documents that will verify your monthly living expenses
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