Fill and Sign the Minnesota Parentage Form

Client Information Questionnaire Parentage 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. Do not be concerned if you cannot answer some of the questions. The completed questionnaire will be kept confidential and will remain in our possession. Please print your answers. Date: ___________________ Referred by: ___________________ PERSONAL INFORMATION - CLIENT : 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 ____________________________ Telephone Number ____________________________ - 1 - Relationship to you ____________________________ 14. ADDRESS FOR MAIL IF DIFFERENT THAN HOME ADDRESS ____________________________ 15. All children born to or adopted by you, if any: Child's Child's Child's Child's Name Birthdate Age Mother/Father ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ 16. How was custody of the minor children awarded? ______________________ 17. What visitation was provided? ____________________________ 18. What are the current custody/visitation arrangements? _______________________ 19. Who claims the tax exemptions for the minor children? ________ 20. Who provides medical insurance for the children? ________ 21. Are the children beneficiaries of any life insurance policies? ________ 22. Maintenance and support payments received by you : Maintenance $ ________ per ________ from ________ Child Support $ ________ per ________ from ________ 23. Maintenance and support payments paid by you : Maintenance $ ________ per ________ from ________ Child Support $ ________ per ________ from ________ CLIENT EMPLOYMENT INFORMATION: 1. Employer ____________________________ 2. Address ____________________________ - 2 - 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 Rental Income Yes No Other Income Yes No If Yes, What: ____________________________ - 3 - 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 : 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 ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ - 4 - ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ OTHER PARTY 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. 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 Birthdate Age Mother/Father ________ ___ ________ ___ ________ ________ - 5 - ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ ________ ___ ________ ___ ________ ________ OTHER PARTY 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. 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) _____________________ - 6 - 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 ________ OTHER PARTY 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 - 7 - ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ ________ ________ $ ________ $ ________ ________ 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. 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 ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ - 8 - ________ ________ $ ________ $ ________ ________ ________ $ ________ $ ________ 10. Assets, including any homestead or other real estate, awarded to your ex-spouse by the Judgment and Decree: - 9 - 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 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: ________ - 10 - 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? ____________________________ 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. - 11 -