MATRIMONIAL CLIENT INFORMATION FORM
Date: ______________________________
You chose this office because:
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Referred by Lawyer/Law Firm
Name: ______________________________
Referred by Former Client/Friend
Name: ______________________________
You are a Former Client
Yellow Pages
Newspaper
Seminar
Name: ______________________________
Other:________________________________________________________________________
1. Your full name: ____________________________________________________________________
First
Middle
Last
Maiden
a) Do you seek the return of your maiden name or a prior name?
_____
Yes
____
No
2. Your present address: _______________________________________________________________
Street
City
____________________________________________________
State
Zip Code
a) Address of marital residence if different from your present address:
____________________________________________________
Street
City
____________________________________________________
State
Zip Code
3. Home phone: ______________________________________________________________________
4. Email Address: ____________________________________________________________________
5. Age: ____________________________
Date of Birth: ________________________________
6. How long in State: __________________________________________________________________
7.
If you wish mail from this office to be sent to a different address, please furnish the desired
address: _______________________________________________________________________
______________________________________________________________________________
8. Employer: ________________________________________________________________________
9. Business phone: ___________________________________________________________________
10. Business address:
____________________________________________________
Street
City
____________________________________________________
State
Zip Code
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11. Job title: __________________________________________________________________________
12. Salary: ___________________________________________________________________________
13. Overtime: _________________________________________________________________________
14. How long at present job: _____________________________________________________________
15. Other skills/training/education: ________________________________________________________
________________________________________________________________________________
16. Company car: _____________________________________________________________________
17. Expense Account: __________________________________________________________________
18. Stocks, bonds: _____________________________________________________________________
19. Other benefits: _____________________________________________________________________
20. Indicate whether you receive or have received:
Food Stamps:__________________
Welfare: ______________________
Unemployment: ________________
Social Security: ________________
Disability: _____________________
21. Other income: (i.e., rental, interest, pension, inheritance)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SPOUSE OR FORMER SPOUSE (if Post-Judgment)
1. Full name: ________________________________________________________________________
First
Middle
Last
Maiden
2. Present address:
____________________________________________________
Street
City
____________________________________________________
State
Zip Code
b) Address of marital residence if different from your present address:
____________________________________________________
Street
City
____________________________________________________
State
Zip Code
3. Home phone: ______________________________________________________________________
4. Email Address: ____________________________________________________________________
5. Age: ____________________________
Date of Birth: ________________________________
6. How long in State: __________________________________________________________________
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7. Employer: ________________________________________________________________________
8. Business phone: ___________________________________________________________________
9. Business address:
____________________________________________________
Street
City
____________________________________________________
State
Zip Code
10. Job title: __________________________________________________________________________
11. Salary: ___________________________________________________________________________
12. Overtime: _________________________________________________________________________
13. How long at present job: _____________________________________________________________
14. Other skills/training/education: ________________________________________________________
15. Company car: _____________________________________________________________________
16. Expense Account: __________________________________________________________________
17. Stocks, bonds: _____________________________________________________________________
18. Other benefits: _____________________________________________________________________
19. Indicate whether you receive or have received:
Food Stamps:__________________
Welfare: ______________________
Unemployment: ________________
Social Security: ________________
Disability: _____________________
20. Other income: (i.e., rental, interest, pension, inheritance)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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CHILDREN
1.
How many children do you and your spouse have from this marriage: ______________________
2.
How many children do you have from prior marriages? __________________________________
How many children does your spouse have from prior marriages? _________________________
3.
Please list the names, ages and birth dates of all children living with you and/or your spouse:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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MARRIAGE
1. Are you separated at this time? ________________________________________________________
2. Date of separation: _________________________________________________________________
3. If so, how are you supporting yourself and/or your children: __________________________________
______________________________________________________________________________
______________________________________________________________________________
4.
Date of marriage: ________________________________________________________________
5.
Place of marriage: _______________________________________________________________
6.
Religious ceremony?
7.
Any prior separations or divorce actions between you and your spouse? ____________________
_____
Yes
_____
No
________________________________________________________________________________
________________________________________________________________________________
8.
Are you considering divorce?
_____
Yes
_____
_____
Not sure
_____
_____
Not sure
_____
No
9. If so, will your spouse contest your action?
Yes
_____
No
10. Is your spouse considering divorce?
Yes
11.
No
Do you think your spouse will be agreeable as to the custody of the children?
Yes
12.
_____
_____
No
_____
Not sure
_____
Has your spouse ever threatened to seek custody of the children?
________________________________________________________________________________
________________________________________________________________________________
13.
Have you sought personal or marital counseling as a result of marital problems? If so, please
state the counselors, number of visits, whether you attended with your spouse and status:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14.
Do you anticipate any particular problems in this matter with your
spouse?
Yes
_____
No
_____
If so, please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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15. Check any that apply to your case:
Finances ___________________ In-Laws ________________ Sex __________________
Raising Children _____________ Drinking________________ Drugs ________________
Gambling ___________________ Another man ____________ Another woman_________
Physical Abuse ______________ Mental Abuse ___________________________________
No communication ____________ Excessive Absence_______________________________
Personality change in spouse ___
in yourself
Other _______________________________________________________________________
____________________________________________________________________________
16.
Is there any danger of extreme violence?
Yes
_____
No
_____
If so, please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
17.
18.
Have you been to Court with your spouse before?
Yes
_____
No
_____
If so, please describe these proceedings and provide dates:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
19.
Is there an Order currently in effect?
Yes
_____
No
_____
If so, please explain what the Order provides:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
20.
Are you covered by medical insurance?
Yes
_____
No
_____
If so, what is the name of your insurer?
________________________________________________________________________________
21.
Who pays the premiums? _________________________________________________________
22.
What type of insurance is this? _____________________________________________________
23.
What credit cards are held by you or your spouse? _____________________________________
________________________________________________________________________________
________________________________________________________________________________
24.
Does your spouse have authority to charge in your name? _______________________________
25.
Who has possession of the above cards? _____________________________________________
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26.
Do you have a Will?______________________________________________________________
Does your spouse have a Will? _____________________________________________________
27.
Do you and your spouse have a Pre-Nuptial or Pre-Marital Agreement? _____________________
28.
Do you and your spouse have an Interspousal or Property Settlement Agreement? ____________
29.
Do you think your spouse has hidden property from you or may hide property in the future? _____
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PROPERTY
1. Who has the best financial information?
Me
_____
Spouse _____
About equal
2. Please provide current values or estimates for the following:
Present value of home
Present value of
Mortgage or other liens
Who holds the mortgage(s)
Property in the home
Jewelry, collections
Antiques
Your car
Spouse’s car
Cash on hand
Cash in savings
Trust funds for children
Stocks
Land
Current debts
Bank debts
Charge card debts
________________
Do you have life insurance?
Does your spouse have
life insurance?
________________
Do you have a pension,
retirement or profit sharing
plan?
Does your spouse have a
pension, retirement or
profit sharing plan?
Other assets or liabilities
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Please number the following in order of importance to you:(1-4)
_____
_____
_____
_____
Revenge against spouse
Fair resolution of all issues
Getting all of this over as quickly as possible
Financial security for yourself and children
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Please take this home and complete the following information and return same to our office within
one week.
LIFE INSURANCE
Name of Company: _________________________
Policy Number: ____________________________
Face Amount: _____________________________
Policy Owner: _____________________________
Address: __________________________________
Beneficiary: ________________________________
Name of Insured: ____________________________
Policy Term (if applicable): ____________________
HEALTH INSURANCE
Name of Insured: ______________________________________________________________________
Name of Company: _________________________ Address: __________________________________
I.D. Number: ______________________________ Group Number: _____________________________
Coverage Type:
[ ] Single
[ ] Parent/Child
[ ] Family
[ ] Optical
[ ] Hospital
[ ] Major Medical
[ ] Dental
[ ] Drug
[ ] Diagnostic
AUTOMOBILE INSURANCE
Name of Company: ____________________________________________________________________
Address of Company: __________________________________________________________________
Policy Number: _______________________________________________________________________
Policy Expiration: ___________________________ Make of Vehicle: ____________________________
Model of Vehicle: ___________________________ Year of Vehicle: _____________________________
Coverage Limits: ______________________________________________________________________
Lawsuit Threshold:
[ ] YES
[ ] NO
Umbrella Coverage:
[ ] YES
[ ] NO
Umbrella Coverage $ _________________
Driver(s) of Vehicles:
Lien Holder/Lessor (if applicable): _________________________________________________________
Address of Lien Holder/Lessor: ___________________________________________________________
Use of Vehicle:
[ ] Personal
[ ] Business
[ ] Personal/Business
HOMEOWNERS INSURANCE
Name of Company: ____________________________________________________________________
Address of Company: __________________________________________________________________
Policy Number: ____________________________ Policy Expiration Date: _______________________
Address of Covered Residence: __________________________________________________________
Coverage Limits: ______________________________________________________________________
Umbrella Coverage:
[ ] YES
[ ] NO
Umbrella Coverage $ _________________
Mortgagee (if applicable):
Address of Mortgagee:
Rider:
[ ] Jewelry
[ ] Furs
[ ] Artwork
[ ] Other
DISABILITY INSURANCE
Name of Insured: ______________________________________________________________________
Name of Company: ____________________________________________________________________
Address: ____________________________________________________________________________
I.D. Number: ______________________________ Group Number: _____________________________
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