DOMESTIC RELATIONS INTAKE SHEET CASE NO.

_________________________
Referred by: _________________________
Date of Interview: ____________________ ____ DIVORCE
____ DISSOLUTION
____ LEGAL SEPARATION
CLIENT: __________________________________________________ DOB: ______________ SSN: ____________________ ____ CUSTODY____SUPPORT
__________________OTHER
Address: (city,state,zipcode): _________________________________________________________________________________ FEE/RETAINER QUOTED:
__________________________
Phone No: (H) ____________________________ (W) ____________________________ (C) ____________________________ RETAINER PAID: __________
__________________________
E-mail/Other: ______________________________________ DL No. ______________________________ DATE PAID: ______________

Occupation: _______________________ Employer _______________________________________________ Full/Parttime Salary/hourly rate _______________

Address of Employer (city,state,zipcode): _________________________________________________________ Pay period: ________________________________

Marital address: ________________________________________________________________________________________________________________________

Non-marital assets: ______________________________________________________________________________________________________________________

No. of marriage(s): ______________________ Name of former spouse(s): ________________________________________________________________________

Number/Names of children from previous marriage(s) _________________________________________________________________________________________

Other court cases: _____________________________________________________________________________________________________________

SPOUSE: __________________________________________________ DOB: _______________ SSN: _____________________ DL No: ____________________

Address: (city,state,zipcode): _________________________________________________________________________________

Phone No: (H) ____________________________ (W) ________________________ (C) ______________________ E-mail/other: ___________________________

Occupation: _______________________ Employer _______________________________________________ Full/Parttime Salary/hourly rate _______________

Address of Employer (city,state,zipcode): _________________________________________________________ Pay period: ________________________________

Non-marital assets: ______________________________________________________________________________________________________________________

No. of marriage(s) _______________________ Name of former spouse(s): ________________________________________________________________________

Number/Names of children from previous marriage(s) _________________________________________________________________________________________

Other court cases: ______________________________________________________________________________________________________________

Attorney for spouse(if known) _____________________________________________________________________________________________________________

Address: (city,state,zipcode): _________________________________________________________________________________

Phone No: (H) ____________________________ (W) ________________________ (C) ______________________ E-mail/other: ___________________________

DATE OF MARRIAGE: ___________________________________________ DATE OF SEPARATION: ____________________________________________

Place of marriage: _______________________________ Maiden/former name restored: YES/NO Maiden/former name: ___________________________________

Witness name/address/phone no: ___________________________________________________________________________________________________________

CHILDREN OF THIS MARRIAGE:

Name Age SSN DOB Residing with

1._____________________________________ ________ ______________________________ _______________

_________________________________
2._____________________________________ ________ ______________________________ _______________
_________________________________
3._____________________________________ ________ ______________________________ _______________
_________________________________
4._____________________________________ ________ ______________________________ _______________
_________________________________

CHILDREN OF PRIOR MARRIAGE(S)/RELATIONSHIP(S):

Name Age SSN DOB Residing with

1._____________________________________ ________ ______________________________ _______________
_________________________________
2._____________________________________ ________ ______________________________ _______________
_________________________________
3._____________________________________ ________ ______________________________ _______________
_________________________________
4._____________________________________ ________ ______________________________ _______________
_________________________________

ADDITIONAL CONTACT PERSON: ____________________________________________________________________________________________________

ADDITIONAL EMPLOYMENT INFORMATION:

CLIENT SPOUSE

Employer: _________________________________________________________ _______________________________________________________________

Length of Employment: ______________________________________________

_______________________________________________________________

How Often Paid: ____________________________________________________

_______________________________________________________________

Gross Earnings per Pay: ______________________________________________

_______________________________________________________________

Deductions: ____________________________________________________
_______________________________________________________________

Net Earnings per Pay: ________________________________________________

_______________________________________________________________

Annual Amount: ____________________________________________________

_______________________________________________________________

Other Income: ______________________________________________________ ______________________________________________________________

(Source and amount)

If Unemployed:

Date Last Employed: _____________________________________________

_______________________________________________________________

Employer’s Address: ______________________________________________

_______________________________________________________________

Unemployment Compensation: ______________________________________

_______________________________________________________________

Worker’s Compensation: __________________________________________

_______________________________________________________________
(Amount & account/case no.)

REAL ESTATE:

(A) Address/Parcel Number: __________________________________________

_______________________________________________________________

Purchase Date: __________________________________________________

_______________________________________________________________

1st Mortgage Company/Account Information/ Amount of Mortgage:

_______________________________________________________________
_______________________________________________________________

Address: ________________________________________________________
_______________________________________________________________

Mortgage Company/Address: _______________________________________

_______________________________________________________________

Purchase Date: ___________________________________________________ -

_______________________________________________________________

2nd Mortgage Company/Account Information/ Amount of Mortgage:

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 ________________________________________________________________
_______________________________________________________________

Address: ________________________________________________________
_______________________________________________________________

Other: __________________________________________________________
_______________________________________________________________

(B) Address/Parcel Number: ____________________________________________

_______________________________________________________________

Purchase Date: ___________________________________________________

_______________________________________________________________

1st Mortgage Company/Account Information/ Amount of Mortgage:

________________________________________________________________
_______________________________________________________________

Address: ________________________________________________________
_______________________________________________________________

Mortgage Company/Address: ________________________________________

_______________________________________________________________

Purchase Date: ___________________________________________________

_______________________________________________________________

2nd Mortgage Company/Account Information/Amount of Mortgage:

________________________________________________________________
_______________________________________________________________

Address: ________________________________________________________
_______________________________________________________________

Other: __________________________________________________________
_______________________________________________________________

(C) Address/Parcel Number: ____________________________________________

_______________________________________________________________

Purchase Date: ___________________________________________________

_______________________________________________________________

1st Mortgage Company/Account Information/Amount of Mortgage:

_______________________________________________________________
_______________________________________________________________

Address: _______________________________________________________
_______________________________________________________________

Mortgage Company/Address: ______________________________________

_______________________________________________________________

Purchase Date: __________________________________________________

_______________________________________________________________

2nd Mortgage Company/Account Information/Amount of Mortgage:

_______________________________________________________________
_______________________________________________________________

Address: _______________________________________________________
_______________________________________________________________

Other: _________________________________________________________
_______________________________________________________________

BUSINESS:

Name of Business/Type: ______________________________________________

_______________________________________________________________

Address: __________________________________________________________
_______________________________________________________________

Date Formed/Other Information: ___________________________________________________________________________________________________________

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______________________________________________________________________________________________________________________________________

HOUSEHOLD GOODS & FURNISHINGS:

Marital – (M) Non-Marital – (N) List approximate value of each item listed, i.e.., Color TV $200; China Cabinet $1200

(A) ______________________________________ (I) ______________________________________ (Q) _____________________________________

(B) ______________________________________ (J) ______________________________________ (R) _____________________________________
(C) ______________________________________ (K) _____________________________________ (S) _____________________________________
(D) ______________________________________ (L) _____________________________________ (T) _____________________________________
(E) ______________________________________ (M) _____________________________________ (U) _____________________________________
(F) ______________________________________ (N) _____________________________________ (V) _____________________________________
(G) ______________________________________ (O) _____________________________________ (W) _____________________________________
(H) ______________________________________ (B) _____________________________________ (X) _____________________________________

AUTOMOBILES:
Year/Make Titled to Fair Market Value Monthly Payment Amount
Owed
____________________________ ____________________________ _____________________ ______________________ _____________________

____________________________ ____________________________ _____________________ ______________________ _____________________

____________________________ ____________________________ _____________________ ______________________ _____________________

____________________________ ____________________________ _____________________ ______________________ _____________________

Do you need beneficial use of any of the above vehicles? If yes, which vehicle? _____________________________________________________________________

DEBTS:
Account Debtor Balance Payments Purpose

______________________ ____________________________ __________________ _________________

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DEBTS:
Account Debtor Balance Payments Purpose

______________________ ____________________________ __________________ _________________

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______________________ ____________________________ __________________ _________________

__________________________________________

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______________________ ____________________________ __________________ _________________
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______________________ ____________________________ __________________ _________________

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BANK ACCOUNTS:
Type H/W/Joint Institution/Location Account No. Balance

_________ _____________ ___________________________________________________ ___________________________ ________________________

_________ _____________ ___________________________________________________ ___________________________ ________________________

_________ _____________ ___________________________________________________ ___________________________ ________________________

_________ _____________ ___________________________________________________ ___________________________ ________________________

_________ _____________ ___________________________________________________ ___________________________ ________________________

STOCKS/BONDS:
Identify Name of H/W/Joint Institution/Location Account No. Value

________________________________ ___________ ______________________________________________ _____________________ _______________

________________________________ ___________ ______________________________________________ _____________________ _______________

________________________________ ___________ ______________________________________________ _____________________ _______________

________________________________ ___________ ______________________________________________ _____________________ _______________

RETIREMENT ACCOUNTS:
Identify Name of Location (include address) Value

Husband: ______________________________________ _____________________________________________________________________ ______________

Wife: _________________________________________ _____________________________________________________________________ ______________

INSURANCE POLICIES:
Do you or your spouse carry health/major medical insurance? If yes, please complete the following:

Who carries insurance: Company Name Participant/RX card Cost

(wife/husband/both) Address/Phone No. available Single Family

Life:
Name of Insured Company Name Policy No. Face Value Cash Value Beneficiary

_____________________________ _____________________________ _______________________ _____________ _____________ __________________

_____________________________ _____________________________ _______________________ _____________ _____________ __________________

_____________________________ _____________________________ _______________________ _____________ _____________ __________________

_____________________________ _____________________________ _______________________ _____________ _____________ __________________

CASH ON HAND: _______________

RESIDENCE OF CHILDREN FOR THE LAST FIVE (5) YEARS:

Address With Whom
Child: _______________________ From _____________ to _______________ ____________________________________________________ ______________

Child: _______________________ From _____________ to _______________ ____________________________________________________ ______________

Child: _______________________ From _____________ to _______________ ____________________________________________________ ______________

RESIDENCE OF CHILDREN FOR THE LAST FIVE (5) YEARS:

Address With Whom
Child: _______________________ From _____________ to _______________ ____________________________________________________ ______________

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Child: _______________________ From _____________ to _______________ ____________________________________________________ ______________

WITNESSES FOR TRIAL:

Name Address Telephone Relation to Client Nature of Testimony

___________________________ ____________________________________________ __________________ _______________ ____________-

_____________

___________________________ ____________________________________________ __________________ _______________ ____________-

_____________

___________________________ ____________________________________________ __________________ _______________ ____________-

_____________

___________________________ ____________________________________________ __________________ _______________ ____________-

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___________________________ ____________________________________________ __________________ _______________ ____________-

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___________________________ ____________________________________________ __________________ _______________ ____________-

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___________________________ ____________________________________________ __________________ _______________ ____________-

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(For Attorney Only)
EVIDENCE:

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EDH: 05/07