Fill and Sign the Mn Questionnaire 497312352 Form

Client Information Questionnaire Marriage Dissolution 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 ____________________ Telephone Number ____________________ Relationship to you ____________________ 16. ADDRESS FOR MAIL IF DIFFERENT THAN HOME ADDRESS - 1 - ____________________ YOUR 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 S State M 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 - 2 - 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 ________ 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 ____________________ $ ________ $ ________ ________ ____________________ $ ________ $ ________ ________ - 3 - ____________________ $ ________ $ ________ ________ ____________________ $ ________ $ ________ ________ ____________________ $ ________ $ ________ ________ SPOUSE'S 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 S State M 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) ____________________ - 4 - 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: ________ CHILDREN BORN OR ADOPTED INTO THIS MARRIAGE : [Do not list children from previous marriages or other relationships]: 1. Children: Child's Name Birthdate Age Mother/Father ____________________ ________ ________ ____________________ ____________________ ________ ________ ____________________ ____________________ ________ ________ ____________________ ____________________ ________ ________ ____________________ 2. Do the children now live with Client? Spouse Both 3. Do you want custody of this child/these children? ____________ 4. Do you expect a contest over who should have custody of the children? ____________ Why? ____________________ MARITAL INFORMATION : 1. Did you sign a pre-marital [antenuptial] agreement? ____________ 2. Date of present marriage ____________ 3. City, county, and state where you were married ____________ 4. Are you and your spouse living together? ____________ 5. If not, date of separation ____________ - 5 - 6. Are you, or your spouse, pregnant? ____________ 7. Describe any action that has been taken by either you or your spouse to dissolve this marriage ________________________________________ 8. State the date, purpose and names of individuals involved in any counseling of you and/or your spouse ____________________ 9. Do you feel there is any chance to save this marriage? ____________ 10. What are your primary complaints about your spouse? ____________ 11. What are your spouse's primary complaints about you? ____________ 12. Is there a history of domestic abuse in your marriage relationship? ____________ Describe ____________________ 13. Have you or your spouse ever sought an order for protection as a result of domestic abuse? ____________________ INFORMATION ABOUT YOUR OTHER MARRIAGES OR RELATIONSHIPS : 1. Were you previously married? ____________________ 2. When were you divorced? ____________________ 3. City, county and state of divorce ____________________ 4. Minor children from your previous marriages or relationships: [Do not list children born or adopted into your current marriage]: Full Name Age Birth date Social Security # ____________ ____ _____ ____________ ____________ ____ _____ ____________ ____________ ____ _____ ____________ ____________ ____ _____ ____________ 5. Who received custody? ____________________ 6. If custody was awarded pursuant to a paternity decree, state the date of the paternity decree and the city, county, and state in which it was issued ____________________ 7. Maintenance and child support payments received by you : - 6 - Maintenance $ ____________ per ____________ from ____________ Child Support $ ____________ per ____________ from ____________ Maintenance and child support payments paid by you : Maintenance $ ____________ per ____________ from ____________ Child Support $ ____________ per ____________ from ____________ 8. Assets awarded to you ____________________ INFORMATION ABOUT YOUR SPOUSE'S OTHER MARRIAGES OR RELATIONSHIPS : 1. Was your spouse previously married? ____________________ 2. When was your spouse divorced? ____________________ 3. City, county and state of divorce ____________________ 4. Minor children by from your spouse's previous marriages or relationships: [Do not list minor children born or adopted into your current marriage]: Full Name Age Birthdate Social Security # ____________ ____ _____ ____________ ____________ ____ _____ ____________ ____________ ____ _____ ____________ 5. Who received custody? ____________________ 6. If custody was awarded pursuant to a paternity decree, state the date of the paternity decree and the city, county, and state in which it was issued ____________________ 7. Maintenance and child support payments received by your spouse : Maintenance $ ____________ per ____________ from ____________ Child Support $ ____________ per ____________ from ____________ Maintenance and child support payments paid by your spouse : Maintenance $ ____________ per ____________ from ____________ Child Support $ ____________ per ____________ from ____________ - 7 - 8. Assets awarded to your spouse ____________________ YOUR HEALTH INSURANCE : Coverage provided for: [Check all that apply] Name of Carrier You Spouse Dependents 1. Medical ____________ ______ _____ ____________ 2. Dental ____________ ______ _____ ____________ 3. Optical ____________ ______ _____ ____________ 4. Other ____________ ______ _____ ____________ SPOUSE'S HEALTH INSURANCE : Coverage provided for: [Check all that apply] Name of Carrier You Spouse Dependents 1. Medical ____________________ ______ _____ ____________ 2. Dental ____________________ ______ _____ ____________ 3. Optical ____________________ ______ _____ ____________ 4. Other ____________________ ______ _____ ____________ ASSETS : A. Homestead: 1. Address ____________________ City ____________ County ____________ State ____________ 2. Do you have a copy of a deed to this property? ____________ 3. Is this property Abstract or Torrens? ____________________ If Torrens, Certificate of Title No ____________________ Where is the Certificate of Title? ____________________ 4. When was this homestead purchased? ____________ Cost ____________ - 8 - 5. Amount of down payment $ ___________ 6. Source of down payment ____________________ 7. In whose name(s) is the title? ____________________ 8. What is the present fair market value? $ ___________ 9. Present mortgage or contract for deed balance ____________________ 10. Monthly payment $ ___________ 11. To whom are the payments made? ____________________ 12. Does the payment includes taxes? ____________ Insurance? ____________ 13. What are the yearly taxes? $ ___________ Insurance? $ ___________ 14. Are house payments delinquent? ____________ How much? $ ___________ 15. Describe all improvements made to the property during the marriage ____________________ B. Other Real Estate: 1. Address ____________________ City ____________ County State __________ 2. Type ____________________ 3. Do you have a copy of a deed to this property? ____________________ 4. Is this property Abstract or Torrens? ____________________ If Torrens, Certificate of Title No. ____________________ Where is the Certificate of Title? ____________________ 5. When was it purchased? ____________ Cost $ ___________ 6. Amount of down payment $ ___________ 7. Source of down payment ____________________ 8. In whose name(s) is the title? ____________________ - 9 - 9. Present fair market value $ ___________ 10. Present mortgage or contract for deed balance ____________________ 11. Monthly payment $ ___________ 12. To whom are the payments made? ____________________ 13. Does the payment include taxes? ____________ Insurance? ____________ 14. What are the yearly taxes? $ ___________ Insurance? $ ___________ 15. Are payments delinquent? ____________ How much? ____________ 16. Describe all improvements made to the property during the marriage ____________ C. Other Real Estate: 1. Address ____________________ City ____________ County State       2. Type ____________________ 3. Do you have a copy of a deed to this property? ____________________ 4. Is this property Abstract or Torrens? ____________________ If Torrens, Certificate of Title No. ____________________ Where is the Certificate of Title? ____________________ 5. When was it purchased? ____________ Cost $ ___________ 6. Amount of down payment $ ___________ 7. Source of down payment ____________________ 8. In whose name(s) is the title? ____________________ 9. Present fair market value $ ___________ 10. Present mortgage or contract for deed balance ____________________ 11. Monthly payment $ ___________ - 10 - 12. To whom are the payments made? ____________________ 13. Does the payment include taxes? ____________ Insurance? ____________ 14. What are the yearly taxes? $ ___________ Insurance? $ ___________ 15. Are payments delinquent? ____________ How much? $ ___________ 16. Describe all improvements made to the property during the marriage ________________________________________ WE WILL NEED A COPY OF A DEED OR MORTGAGE CONTAINING THE LEGAL DESCRIPTION FOR EACH PARCEL OF REAL ESTATE. E. Savings Accounts: 1. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ 2. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ F. Certificates of Deposit: 1. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ 2. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ G. Checking Accounts: 1. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ 2. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ - 11 - H. Cash Management or Brokerage Accounts: 1. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ 2. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ I. Stock: 1. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ 2. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ J. Bonds: 1. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ 2. Depository ____________________ Balance $ ___________ Name(s) on Account ____________________ K. Safe Deposit Box: Depository _______________ Describe contents _______________ Who has access? _______________ L. List all Pension/Retirement Plans [IRA, 401(k), Keogh, Profit Sharing, ESOP, SEP, PAYSOP, etc.] Type In Whose Name? Value 1. ____________ ____________ $ ____________ 2. ____________ ____________ $ ____________ - 12 - 3. ____________ ____________ $ ____________ 4. ____________ ____________ $ ____________ M. Does anyone owe you or your spouse money? ____________ 1. Who ____________ ____________ How much $ ____________ 2. Who ____________ ____________ How much $ ____________ N. Did you bring property or money into this marriage? ____________ Describe _______________ O. Did your spouse bring property or money into this marriage?       Describe ________________________________________ P. Describe any inheritance you have received ________________________________________ Q. Describe any inheritance your spouse has received ____________________ R. Do you have any personal injury or worker's compensation claim pending or have you received any settlement or award? ______________________________ S. Does your spouse have any personal injury or worker's compensation claim pending or has your spouse received any settlement or award? ____________ ____________ T. Life Insurance 1. Company ______________________________ 2. Type of Policy _________________________ 3. Name of Insured _______________ 4. Name of Beneficiary _______________ 5. Annual Premium $ ___________ Face Value $ ___________ Cash Value $ ___________ Policy 1: 1. Company _______________ 2. Type of Policy _______________ - 13 - 3. Name of Insured _______________ 6. Name of Beneficiary _______________ Annual Premium $ ___________ Face Value $ ___________ Cash Value $ ___________ Policy 2: 1. Company _______________ 2. Type of Policy _______________ 3. Name of Insured _______________ 7. Name of Beneficiary _______________ Annual Premium $ ___________ Face Value $ ___________ Cash Value $ ___________ U. Motor Vehicles Driven by YOU : 1. Kind ____________ Year ____________ Model ____________ 2. In whose name? _______________ 3. Balance owed $ ___________ Payments $ ___________ Per ____________ 4. Payments made to whom? _______________ Motor Vehicles Driven by SPOUSE : 1. Kind ____________ Year ____________ Model ____________ 2. In whose name? _______________ 3. Balance owed $ ___________ Payments $ ___________ Per ____________ 4. Payments made to whom? _______________ V. Recreational Vehicles: Make and Model Value Payments Balance Due - 14 - Motorcycles ____________ $ ______ $ ______ $ ______ ______ Snowmobiles ____________ $ ______ $ ______ $ ______ ______ Boat, Motor & ____________ $ ______ $ ______ $ ______ ______ Trailer Recreational ____________ $ ______ $ ______ $ ______ ______ Vehicles W. Value of: Jewelry $ ____________ Furs $ ____________ Art $ ____________ Precious Metals $ ____________ Collections [describe] $ ____________ _______________ X. Household Goods and Furnishings: 1. Estimated value _______________ 2. Balance owed $ ___________ Payments $ ___________ Per ____________ 3. Payments made to whom? _______________ Y. Describe any other assets that you know of _______________ DEBTS : Balance Monthly Payment Reason Debt Incurred Person Incurring Debt Creditor Due Payment       $                               $             $                               $             $                               $             $                               $             $                               $       - 15 -       $                               $             $                               $             $                               $             $                               $       MISCELLANEOUS : 1. Do you or your spouse have a will? _______________ 2. When were the wills executed or last revised? _______________ 3. Do you or your spouse desire to have a name change as a result of this proceeding? _________________________ If so, what name is desired? _______________ 4. Are you or your spouse named as a party in any pending lawsuit, including bankruptcy? _______________ A COPY OF THE SUMMONS AND PETITION AND ANY OTHER COURT DOCUMENTS CONCERNING YOUR CASE, IF ANY, AS WELL AS LEGAL DESCRIPTIONS, TAX RETURNS, FINANCIAL STATEMENTS, AND OTHER FINANCIAL RECORDS SHOULD BE PROVIDED AS SOON AS POSSIBLE. 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 ___________________ __________________________________ - 16 -