Fill and Sign the Questionnaire Divorce Form

Divorce Questionnaire PERSONAL INFORMATION Date : Client Spouse Full name Full name Birth date Birth date Age Age Birthplace Birthplace Address Address Work phone Work phone Home phone Home phone Cell phone Cell phone Pager Pager E-mail address E-mail address Fax Fax Social Security no. Social Security no. Driver's License no. State Driver's License no. State Occupational License no(s). Occupational License no(s). Armed Forces status Armed Forces status Next of kin Relation Address Next of kin Relation Address MARRIAGE Date of marriage Date of separation City/County/State How long have you lived in this state? County? No. of previous marriages: yours spouse How previous marriage(s) terminated: Client Spouse Wife’s maiden name Wife’s name before this marriage Does wife desire name change? Yes To what? No Is there a prenuptial or postnuptial agreement? Yes Please attach a copy of the agreement. No What is the primary reason you want this divorce? irreconcilable differences adultery abandonment physical abuse mental abuse spouse’s addiction other CHILDREN 1. Name Birth date Age School Grade Social Security no. Living with Client Spouse 2. Name Birth date Age School Grade Social Security no. Living with Client Spouse 3. Name Birth date Age School Grade Social Security no. Living with Client Spouse 4. Name Birth date Age School Grade Social Security no. Living with Client Spouse 5. Name Birth date Age School Grade Social Security no. Living with Client Spouse Residence of the children during the last five years: Where? With whom? How long? Is wife pregnant? Yes When is birth expected? No Is anyone other than the spouse claimed to be the father? Yes No If yes, who?     Are any of the children adopted? Yes No If yes, who? Do you or your spouse have a health insurance policy that covers the children? Yes No Name of health care insurance provider for children Policy, group, or contract number Paid by whom? Is the premium for the insurance paid through deduction from your or your spouse’s pay? Mine My spouse’s Does your / your spouse's health insurance require that you/he/she have the children as dependents to continue health insurance for them? Yes No Deductible Co-pay on doctor visits Co-pay on prescriptions As to the premium, please state: cost for employee only amount deducted each pay period cost for employee and spouse how often is the deduction made? cost for employee and children weekly every two weeks two times per month once per month If you, your spouse or any of your children have any serious health problems, please describe: Child care: No Yes How many weeks per year? Paid by whom? Weekly cost- During school Summer Are you paying or receiving support for other children? No Yes How much per week? $ No. of children Is your spouse paying or receiving support for other children? No Yes How much per week? $ No. of children Provide copies of the court support orders. Does either party have children from a prior relationship? Yes No Name Parents: Living with Client Spouse Birth date Age Social Security no. Name Parents: Living with Client Spouse Birth date Age Social Security no. Name Parents: Living with Client Spouse Birth date Age Social Security no. CUSTODY AND SUPPORT What do you think the custody and visitation rights should be and why? If you and your spouse have agreed on custody, describe. Does anyone else claim visitation rights with your children? No Yes State the person's name, address, and relationship. Has support been paid since separation? No Yes How much per week? If you and your spouse have agreed on child support, how much per week? Do the children have a custody preference? Yes . Describe No PREVIOUS LITIGATION Has either spouse previously filed for divorce, separation, annulment, custody, etc., in this county or elsewhere? Yes Indicate when and where filed, status of case, case number, and name of judge. No Has there been any previous domestic violence case filed in this county involving you and/or your spouse or any other family member? Yes Indicate when and where filed, status of case, case number, and name of judge. No Does anyone else claim custody over children of you or your spouse? Yes Indicate when and where filed, status of case, case number, and name of judge. No Have you had any cases filed regarding care of the children? Yes Indicate when and where filed, status of case, case number, and name of judge. No Is one of the parties currently under court order to pay support for another child not of this marriage? Yes Indicate when and where filed, status of case, case number, and name of judge. No FAMILY HEALTH AND SOCIAL ISSUES Do you, your spouse, or your children have any serious physical or mental disability, disorder, handicap or incurable disease? Yes Please explain No Any addiction issues with drugs, alcohol? Yes What type of substance? What treatment and by whom? When? Place of treatment Outcome of treatment No Any romantic liaisons by either party? No Yes Who? Any problems with debts? Gambling? Any marriage counseling? No Yes Please explain reason, date, and duration Personal counseling (yours/spouse's) Are you willing to start/continue counseling? Yes No Would you sign a waiver of confidentiality so that we may have access to your records? Yes No Does either spouse wish to reconcile? Yes No If yes, briefly describe Are you or your spouse receiving government aid? Yes Caseworker Case no.      No RESTRAINING ORDER INFORMATION Please describe any violent incidents, including place and time Has either spouse ever been arrested, convicted, imprisoned, or placed on probation? Yes Explain. No Have you or anyone in your household has ever been arrested for anything other than routine traffic tickets, state who, when, why and what: Has your spouse or anyone in your spouse’s household has ever been arrested for anything other than routine traffic tickets, state who, when, why and what: If your spouse says you or anyone in your household is emotionally unstable, state who and why: Physical Description of Client: Race Height Weight Eye color Hair color Glasses: No Yes Worn all the time? Yes No Mustache/beard: Yes Color No Distinguishing scars or tattoos Any current restraining orders? No Yes Physical Description of Spouse: Race Height Weight Eye color Hair color Glasses: No Yes Worn all the time? Yes No Mustache/beard: Yes Color No Distinguishing scars or tattoos Any current restraining orders? No Yes Is carrying a weapon a condition of his/her employment? Yes No EMPLOYMENT Client Spouse Employer Address Date of hire Employer Address Date of hire Occupation Occupation Weekly gross pay Weekly gross pay Weekly take home Weekly take home Pension Pension Early retirement benefits Early retirement benefits Bonuses or commissions Bonuses or commissions Profit-sharing Profit-sharing Total income last year Total income last year Please attach a copy of your last three pay stubs. Indicate if any deductions are mandatory (other than taxes), for example, union dues, pension, etc. Please attach the last two income tax returns (personal and business) with their schedules and W-2 forms. Previous Employer Address Annual Income Previous Employer Address Annual Income Other income sources (pension, retirement, government assistance, veterans benefits, Social Security, investment funds): Type Gross per year In whose name Type Gross per year In whose name Type Gross per year In whose name EDUCATION Client Spouse Highest degree obtained Highest degree obtained High school Date of diploma or GED High school Date of diploma or GED Univ./College Degree Date obtained Univ./College Degree Date obtained Univ./College Degree Date obtained Univ./College Degree Date obtained Additional training Additional training Did either spouse contribute to the education of the other? Yes Describe. No ASSETS (Attach additional sheets if necessary.) List significant items of property you owned before this marriage or received as a gift or inheritance during the marriage. If you no longer have these items, explain what happened to them. List significant items of property your spouse owned before this marriage or received as a gift or inheritance during the marriage. If your spouse no longer has these items, explain what happened to them. List significant items of property you and your spouse received, as a couple, during this marriage as a gift or inheritance. If you or your spouse no longer has these items, explain what happened to them. List significant items of property your children received as a gift or inheritance during your marriage. If your children no longer have these items, explain what happened to them. Real property Resident address Date purchased Purchase price Mortgage co. Account no. In whose name Monthly payments Balance due Paid by Husband Wife Both Land contract In whose name Home equity loan Account no. In whose name Amount of property taxes Are they included in monthly payment? Yes No Additional real estate Address Date purchased Purchase price Mortgage co. Account no. In whose name Monthly payments Balance due Paid by Husband Wife Both Vehicles (car, boat, trailer, recreational vehicle, etc.) 1. Year/make Vehicle identification number In whose name Possession Purchase price Monthly payments Lien holder Balance due 2. Year/make Vehicle identification number In whose name Possession Purchase price Monthly payments Lien holder Balance due 3. Year/make Vehicle identification number In whose name Possession Purchase price Monthly payments Lien holder Balance due 4. Year/make Vehicle identification number In whose name Possession Purchase price Monthly payments Lien holder Balance due Bank accounts or credit union accounts 1. Name of bank and branch Account number Type of account (savings, checking, money market) Signatories Source of funds Balance 2. Name of bank and branch Account number Type of account (savings, checking, money market) Signatories Source of funds Balance 3. Name of bank and branch Account number Type of account (savings, checking, money market) Signatories Source of funds Balance Individual retirement accounts Financial institution Account number Balance In whose name Financial institution Account number Balance In whose name Retirement plans, pensions, Keoghs, 401(k) plans, profit-sharing plans, stock bonus or option plans, etc. (attach copies of plan descriptions and annual reports for each) Employer or financial institution Name and type of plan Vested percentage Value Account no. In whose name Employer or financial institution Name and type of plan Vested percentage Value Account no. In whose name Employer or financial institution Name and type of plan Vested percentage Value Account no. In whose name Investments Broker/ firm Type of investment Account no. In whose name Type of account (savings, checking, money market) Purchase price Current value What was source of stock or funds to purchase? Broker/ firm Type of investment Account no. In whose name Type of account (savings, checking, money market) Purchase price Current value What was source of stock or funds to purchase? Patents, inventions, copyrights, etc. Life insurance Client Spouse Name of insurer Name of insurer Name of insured Name of insured Name of beneficiary Name of beneficiary Type of insurance (term, whole life, etc.)      Type of insurance (term, whole life, etc.)      Policy no. Policy no. Amount of policy Amount of policy Cash surrender value Cash surrender value Loans against policy Loans against policy Business interests (corporations, partnerships, sole proprietorships, etc.) Name and type of business interest Type of ownership interest Value of interest Initial investment and when Additional amounts invested and when Community property (property acquired with your spouse) Have you ever lived in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin)? Yes Provide details and the status of assets brought into this state. No Miscellaneous assets Jewelry Value Art work Value Antiques Value Coin and other collections Value Inheritance Value Annuities Value Safe deposit box Location Accounts receivable Gifts Have you or your spouse made any substantial gifts in the past or placed property in joint names with anyone other than the spouse? Yes Provide details. No Trust beneficiaries Yes Provide details. No Assets held at time of marriage Do you suspect any assets are being given away, sold, or hidden from you? Yes Briefly explain. No EXPENSES Expenses Rent/Mortgage 2nd Mtg/Assoc. Fees Property Tax Electric Gas Water/Sewer Telephone Cell Phone Cable/Satellite Internet Trash Lawn Care/Services Household Maintenance/Repairs Clothing/Laundry Groceries Lunch (school/work) House Insurance Auto Insurance Life Insurance Auto Loan 1 Auto Loan 2 Auto Maintenance Auto Registration Gas/Bus Fare Parking/Tolls Charities Memberships/Hobbies/Lessons Gifts Cigarettes/Alcohol Child Care Medical/Dental (out of pocket) Beauty Security Alarm Student Loans/Tuition Personal Loans Credit Cards Entertainment Vacation Pet Care Other Other Other Other Other Other (select totals below and press F9 key to automatically calculate total Total Expenses= $ 0.00 Total Monthly Income - Monthly Expenses= $ 0.00 LIABILITIES Please indicate with an asterisk any accounts that you have reason to believe are delinquent: Indebtedness (i.e., credit cards, educational loans, personal loans, etc.) 1. Creditor Account no. Type of indebtedness (credit card, etc.) Is the account current? Yes No Present balance due Monthly payment Named borrowers Who will pay until the divorce judgment? 2. Creditor Account no. Type of indebtedness (credit card, etc.) Is the account current? Yes No Present balance due Monthly payment Named borrowers Who will pay until the divorce judgment? 3. Creditor Account no. Type of indebtedness (credit card, etc.) Is the account current? Yes No Present balance due Monthly payment Named borrowers Who will pay until the divorce judgment? 4. Creditor Account no. Type of indebtedness (credit card, etc.) Is the account current? Yes No Present balance due Monthly payment Named borrowers Who will pay until the divorce judgment? Delinquent Debt Type Amount Length of Time Overdue Mortgage Property Tax Income Tax Car Loan Credit Card Business Debt Other Other obligations (for example, spousal support to a former spouse) Is anyone other than the spouse and identified children financially dependent on you? Yes Give details. No On your spouse? Yes Give details. No RELIEF TO BE REQUESTED Divorce Separate maintenance Annulment Custody of children Visitation rights Child support payments Alimony Spouse to vacate home Contribution to your attorney fees Restoration of former name Procurement of $ in life insurance to secure child support Property division Property injunction Domestic abuse restraining order Health insurance for children or yourself Home utility payments Home insurance (Plaintiff/Defendant) Mortgage payments Debts Other Attorney fee arrangement The items checked below are needed to complete your divorce case file. Please collect the items that have been checked and bring in copies or originals to the paralegal as soon as possible. Items needed Tax returns with schedules and W-2s-last two years Paycheck stubs-last two months You Your spouse Mortgage statement: Marital home Vacation property Income property Pension or retirement account statement You Your spouse Car titles You Your spouse Life insurance cash value statement Savings account statements Investment account balance statements Appraisal for Appraisal for Prenuptial or postnuptial agreement Past three years tax returns, including W-2 forms Current pay stubs from January to present Past six months bank statements for all checking and savings accounts (upon receiving it, provide current months bank statement) Verification of debts (i.e., credit card statements, invoices, monthly statements, etc.) Verification of assets (i.e., monthly or quarterly statement of any asset listed above in General Information Sheet) Vehicle titles Boat titles, Motorcycle titles NADA (blue book) value of automobiles (highlight car value - you may obtain this information from a bank, car dealership, etc.) Warranty Deed or Quit Claim Deed to all real estate, including residence and/or any and all land. Verification of medical insurance cost for children only Verification of monthly day care cost for children Costs of transportation for visitation Verification of other child support payments made either by you or your spouse for any children of a previous marriage or children prior to marriage Certificates of Deposit