Full Name
Nickname
Date of birth
Address
City
State
Postal code
Other Phone
Email
*
Employer
Work Phone
Employer's Address
Employer's Phone
Occupation
Length of Employment
Gross Salary/Monthly
Education
Have you retained any other attorney(s) on this matter prior to coming to this office? (If yes, please provide the attorney(s) name, date retained, and reason for discontinuing service.
Date of Marriage
Place
Date of Separation
Issues in Marriage Include:
Drugs/Alcohol
Sexual Infidelity
Financial Disputes
Mental Abuse
Physical Violence
Religion
Incompatibility
Children
Other
Please state the county where you live and the length of time there:
Do you have criminal history? If so, offense, county, year, disposition:
Have you been married before? If so, to whom and dates of marriage:
Do you pay or receive child support? If so, amount:
1. Child's Name
1. Child's Sex
1. Child's Place of Birth
1. Child's DOB
2. Child's Name
2. Child's Sex
2. Child's Place of Birth
2. Child's DOB
3. Child's Name
3. Child's Sex
3. Child's Place of Birth
3. Child's DOB
4. Child's Name
4. Child's Sex
4. Child's Place of Birth
4. Child's DOB
Additional Children
Do the children have valuable property, trust funds, etc? If so, describe:
Will there be a dispute over child custody?
If not, custody will be with whom:
Where are the children living currently?
Spouse/Other Party Name:
Spouse/Other Party DOB:
Spouse/Other Party Place of Birth:
Spouse/Other Party Address:
Spouse/Other Party Phone:
Address for Service of Citation:
Has opposing party been married previously? If so, to whom and dates of marriage:
Does opposing party pay or receive child support, If so, amount:
1. Child of Previous Marriage Name
1. Child of Previous Marriage Sex
1. Child of Previous Marriage Birthplace
1. Child of Previous Marriage DOB
2. Child of Previous Marriage Name
2. Child of Previous Marriage Sex
2. Child of Previous Marriage Place of Birth
2. Child of Previous Marriage DOB
3. Child of Previous Marriage Name
3. Child of Previous Marriage Sex
3. Child of Previous Marriage Place of Birth
3. Child of Previous Marriage DOB
4. Child of Previous Marriage Name
4. Child of Previous Marriage Place of Birth
4. Child of Previous Marriage DOB
Will the wife’s maiden/prior name be restored?
Yes
No
If so, please provide full name:
Have you filed taxes for all previous years?
Who prepared the tax returns?
Refund received? If so, amount:
Would you like anyone other than you to receive information about this case? If so, what is the name of this person(s) and their address and telephone number:
How did you hear about our office?
What is your expectation regarding the outcome of this case?
Your Name:
Today's Date:
Submit