MODIFICATION WORKSHEET
A.
CLIENT INFORMATION:
Full Name: (Mr. or Mrs.) ______________________________________________________________________
Maiden / Prior Name (if applicable) _____________________________________________________________
Residence Street Address: _____________________________________Lived here since: _________________
City: ___________________ State: ________ Zip: _________ County: _________________________________
Home Phone No.: ______________ Cell No.: ___________________ Email: ___________________________
(please do not supply any phone numbers or email address that are not “safe” contacts for you)
Mailing Address: (safe address for receiving mail)__________________________________________________
City: ___________________ State: ________ Zip: _________ County: _________________________________
Employer:__________________________________________________________________________________
Business Address: __________________________________________________________________________
City: ___________________ State: ________ Zip: _________ County: _________________________________
Business Phone:__________________ Annual Gross Income: $ ___________ Commission (Yes / No) _______
How do you get paid: Hourly $_______ Salary $_________ Weekly, Bi-weekly, other:_____________________
Date of Birth: ______________________ Age: ____ City and State of Birth: ____________________________
Social Security No.: ______________________ Currently Married?________Race: _______________________
B.
OPPOSING PARTY INFORMATION:
Full Name: (Mr. or Mrs.) ______________________________________________________________________
Maiden / Prior Name (if applicable) _____________________________________________________________
Residence Street Address: ____________________________________Lived here since: _________________
City: ___________________ State: ________ Zip: _________ County: ________________________________
Home Phone No.: __________________ Cell No.: ___________________ Email:_______________________
Mailing Address: ____________________________________________________________________________
City: ___________________ State: ________ Zip: _________ County: _________________________________
Employer:__________________________________________________________________________________
Business Address: __________________________________________________________________________
Form #: FL204
Revised: 06/13
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City: ___________________ State: ________ Zip: _________ County: ________________________________
Business Phone:__________________ Annual Gross Income: $ ___________ Commission (Yes / No) _______
How does this party get paid: Hourly $________ Salary $_________ Weekly, Bi-weekly, other:______________
Date of Birth: ______________________ Age: ____ City and State of Birth: ____________________________
Social Security No.: ______________________ Currently married? _______ Race: _______________________
Name and Address of other Attorney (if known): ___________________________________________________
C. GENERAL INFORMATION/HISTORY OF PRIOR ACTION RELEVANT TO THIS ACTION:
Date of Divorce: _________ Court Where Final: Superior Court of ________ County, State of _______
Other Court Orders:__________________________________________________________________
Is either party in the military (specify) ____________________________________________________
Name of Attorney who represented you:__________________________________________________
Name of Attorney who represented opposing party:_________________________________________
(Please supply copies of any previous court orders)
D. CHILDREN:
All children who are subject to this action: (Please supply copies of court orders)
Full Name:
M or F
Date of Birth
Age
Currently Resides With:
Any other children currently residing with you, but not subject to this action: (Please supply copies of court orders)
Full Name:
M or F
Date of Birth
Age
Custody by Court Order?
Any children residing with opposing party: (Please supply copies of court orders, if obtainable)
Full Name:
Form #: FL204
Revised: 06/13
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M or F
Date of Birth:
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Age
Custody by Court Order?
E. CASE SPECIFIC QUESTIONS: (Please note that Modification cases cover a large spectrum of issues and it would be difficult to
list every possible situation. Please feel free to add any information specific to your case under the appropriate category or list additional
information in the “OTHER” section at the end of this worksheet).
What areas do you anticipate modifying?

I. Custody/Visitation

II. Child support

III. Alimony

IV. Tax Deduction

V. Medical Insurance

VI. Other: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I. If Custody needs to be modified, please indicate below:
Reason for custody/visitation modification:

Child has elected to change custodial parents and has or will sign an election affidavit (must be at lease 14
years of age)

Custodial parent is no longer fit to take care of the child. Explain:___________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Mutual Agreement of the parties.
Physical custody to be defined as: (Physical custody is who the child(ren) will live with)

Mother

Father

Joint

Other:____________________

Not Applicable
Form #: FL204
Revised: 06/13
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Legal Custody to be defined as: (Legal custody is who makes the major decisions with regards to the child(ren)
including medical, dental, education, religion)

Mother

Father

Joint

Other:____________________

Not Applicable
Tie-breaking ability. If you selected joint legal custody on the proceeding question, someone will need to have the
tie-breaking ability in the event that, after a good-faith attempt to negotiate, you and your spouse are unable to agree
on a legal issue concerning the child(ren). Therefore, the following party or parties shall have the tie-breaking ability:

Mother (all issues)

Father (all issues)

Medical only to be determined by (circle one) Mother / Father / Pediatrician or Medical Provider…

Dental only to be determined by (circle one) Mother / Father / Dentist or Orthodontist…

Education to be determined by (circle one) Mother / Father / School Teacher or Counselor

Religion to be determined by (circle one) Mother / Father / Other: ___________________
Visitation or custody period for the non-custodial parent can be any arrangement that you and your spouse can agree
to, however, a specific schedule must be included in your Agreement. Please describe the visitation schedule that
you like for the non-custodial parent. (Choose either A, B or C)
A)
Weekends:
The first and third weekends of every month from Friday until Sunday. The first
and third weekends shall be defined as the weekends containing the first and third
Fridays of the month.
The weekend of the first, third, and fifth Friday of each month.
The weekend of the second and fourth Friday of each month.
Every other weekend.
OR……
B)
Form #: FL204
Revised: 06/13
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Extended Weekends:
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Consisting of Thursday from release from school until Monday morning at the
time school commences (If not in school, then from 6:00 p.m. Thursday to 6:00
p.m. Monday) The children shall be required to attend school on Friday, if it is a
regular school day.
Consisting of Friday from release from school until Monday morning at the time
school commences (If not in school, then from 6:00 p.m Friday to 6:00 p.m.
Monday)
If Friday or Monday is a school holiday, such as a teacher’s workday, the parent
exercising weekend visitation shall be entitled to the school holiday as well.
OR…..
C)
Rotating Weeks:
The parties shall be entitled to share custody of the child by alternating weeks of
custody, with each party having the child for seven consecutive days from
Saturday at 6:00 p.m. to Saturday at 6:00 p.m.
Holidays: Children shall spend holidays with each parent on the following schedule:
Holiday
Spring vacation, from 6:00 p.m. on the day school
lets out for vacation, until 6:00 p.m. on the day
before the child(ren) return to school. If none
of the child(ren) is enrolled in school, this
vacation shall be for up to one week (seven
consecutive days) during the months of March
or April; provided that the visiting parent shall
give written notice of the chosen week to the
other parent at least 30 days prior to the
beginning of this visitation.
With Father
Even-number years
Odd-number years
With Mother
Odd-number years
Even-number years
Easter weekend, 6:00 p.m. Friday to 6:00 Sunday,
provided that it does not conflict with Spring
vacation above.
Even-number years
Odd-number years
Odd-number years
Even-number years
Mother's Day, from 9:00 a.m. to 6:00 p.m.
Mother’s Day Weekend, 6:00 p.m. Friday to 6:00
p.m. Sunday
Memorial Day weekend, 6:00 p.m. Friday to 6:00
p.m. Monday
NOT APPLICABLE EVERY YEAR
Even-number years
Odd-number years
Father's Day, from 9:00 a.m. to 6:00 p.m.
EVERY YEAR
Father’s Day Weekend, 6:00 p.m. Friday to 6:00
Form #: FL204
Revised: 06/13
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Odd-number years
Even-number years
NOT APPLICABLE
p.m. Sunday
Fourth of July, from 10:00 a.m. to midnight
Fourth of July overnight, from 10:00 a.m. on the
holiday until 10:00 a.m. the next morning
Labor Day weekend, 6:00 p.m. Friday to 6:00 p.m.
Monday
Even-number years
Odd-number years
Odd-number years
Even-number years
Even-number years
Odd-number years
Odd-number years
Even-number years
Fall Break (If applicable), 6:00 p.m. on the day of
release from school until 6:00 p.m. on the day
before they are to return to school
Thanksgiving weekend, 6:00 p.m. Wednesday to
6:00 p.m. Sunday
-OR-
Even-number years
Odd-number years
Odd-number years
Even-number years
Even-number years
Odd-number years
Odd-number years
Even-number years
First part Thanksgiving day, 10:00 a.m. to 2:00
p.m.
Even-number years
Odd-number years
Odd-number years
Even-number years
Even-number years
Odd-number years
Odd-number years
Even-number years
First part of Christmas vacation, from 6:00 on the
day school lets out for vacation, until 12:00
noon on December 25th. If none of the
child(ren) is/are enrolled in school, this
visitation shall be from 6:00 p.m. on
December 20th until 12:00 noon on
December 25lh.
Even-number years
Odd-number years
Odd-number years
Even-number years
Latter part of Christmas vacation, from 12:00
noon on December 25lh to 6:00 p.m. on the
day before the child(ren) return to school. If
none of the children) is/are enrolled in
school, this visitation shall be from 12:00
noon on December 25th until 6:00 p.m. on
January 1".
Even-number years
Odd-number years
Odd-number years
Even-number years
Latter part Thanksgiving day, 2:00 p.m. to 6:00
p.m.
Mother’s Birthday, if on school day from 4:00 p.m. NOT APPLICABLE
to 8:00 p.m. If not in school or on
weekend, from 6:00 p.m. to 9:00 p.m.
Father’s Birthday, if on school day from 4:00 p.m. EVERY YEAR
to 8:00 p.m. If not in school or on
weekend, from 6:00 p.m. to 9:00 p.m.
Summer:
Other:
Form #: FL204
Revised: 06/13
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EVERY YEAR
NOT APPLICABLE
Religious holidays should be determined by:

Christian

Jewish

Other: ______________
II. If Child Support is to be Modified:
Please state the reason for the child support modification:

Change in Custody

Increase in income by you

Decrease in income by you

Increase in income by other party

Decrease in income by other party

child is no longer eligible for child support pursuant to previous order
o Reached specific age
o No longer attending school
o Emancipated, married, joined military, deceased

Other: _________________________________________________________________________________
A. Mother’s gross monthly income: _________________________
B. Father’s gross monthly income: __________________________
C. How many children are subject to this action: ______________________________
D. Are there expenses for extracurricular activities? If so, please state these monthly expenses for each child
with specificity:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Form #: FL204
Revised: 06/13
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E. Are there daycare expenses, if so, please list the monthly amount, and which party pays these expenses?
______________________________________________________________________________________
F. Are there extraordinary educational expenses? If so, please explain and provide details of these
expenses?______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
G. Are there extraordinary medical expenses? If so, please explain and provide details of these
expenses?______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
H. Are there special expenses for child rearing such as band, camps, clubs, athletics, etc.? If so, please explain
and provide details of these
expenses?______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I.
Which party is to be considered the non-custodial parent, or the parent required to pay child support?

You

Opposing Party

Neither (shared custody)
If neither, please explain:__________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Child support shall be paid:

Weekly on ____________ (day of the week)

Bi-Weekly (every other week)

Monthly on _____________ (day of month)

Bi-Monthly on ________ and on _________ (days of the month)

Other: __________________________________________________________________________
Form #: FL204
Revised: 06/13
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Child Support shall be paid by:

Check or money order hand-delivered directly to recipient

Check or money order mailed to recipient

Income Deduction Order *Please note:
If Income Deduction Order is requested additional fees will be assessed.
Are there any pre-existing child support orders in this case:
Example: Do you receive child support from a former spouse or do you pay child support to a former
spouse? (circle) Yes/No
Year prior Order entered? __________________
Amount of Child Support Received or Paid? ______________
III.
IS ALIMONY TO BE MODIFIED:

Yes

No
If yes, please state the reason you feel alimony should be modified and how alimony should be modified:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
IV.
IS THERE A CHANGE IN WHO CLAIMS THE CHILDREN ON INCOME TAXES:

No

Yes:
Which party shall be permitted to claim the child/children on their personal income tax returns?

You

Opposing Party

Switch off every other year

Divide the children so that each party claims at least one child per year (if applicable)
V.
MEDICAL INSURANCE:
Is medical insurance provision to be modified?

No

Yes:
Form #: FL204
Revised: 06/13
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If there is currently health insurance in effect, who carries the coverage for the children and who is the insurance
provider:

You. Insurance Provider:__________________________________

Opposing Party. Insurance Provider:______________________________________

Other:___________________________________
VI. OTHER: Please list any other information below which has not been covered above that needs to be modified:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you seeking an award of attorney fees from opposing party for bringing this action?_______________
Form #: FL204
Revised: 06/13
D:\81894447.doc
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