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Download New Client Intake Dissolution (Word Document)
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We know your time is extremely valuable to you. Therefore filling out this form prior to, and bringing it with you to your appointment, allows for more time to discuss the particulars of your case during your consultation and less time spent on gathering personal information on the parties involved. Please take a few moments to fill out the following form with as much information as possible. It is preferred that you send this form to us in advance. You may do so by faxing it at 574-272-8167 or emailing it at [email protected]. If it is not possible to send it in advance, bring it with you to your appointment is acceptable. Thank you! Appointment Date: _______________________________ Time: _______________________ Type of case: Dissolution Legal Separation no Has your case been filed with any Court already? Is there a hearing date & time currently scheduled? no yes Cause No.: ________________________ yes If so, Date/Time ______________________ Married: ____/____/____ Separated: ____/____/____ If Divorced, date finalized: ____/____/____ Would you like the restoration of maiden/previous name? no yes. If so, name: ______________________ Personal Information: __________________________________________ __________________________________________ Your Name Spouse’s Name ___________________________________________ __________________________________________ Your Home Address Spouse’s Home Address ___________________________________________ __________________________________________ Your City, State, Zip Spouse’s City, State, Zip ___________________________________________ __________________________________________ Your Home Phone Spouse’s Home Phone ___________________________________________ __________________________________________ Your Cell Phone Spouse’s Cell Phone ____________________________________________ __________________________________________ Your email address Spouse’s email address _____/_____/______ Your DOB _____-______-______ _____/______/______ _____-_____-______ Spouse’s DOB Your SSN Spouse’s SSN Child(ren)’s Information (please use additional page if needed): _________________________ Name of child _________________________ Name of child _________________________ Name of child _____ ____/____/____ Age DOB _____ ____/____/____ Age DOB _____ ____/____/____ Age DOB Are you or your Spouse currently pregnant? Yes No ______________________ ___________ Daycare/ School Cost ______________________ ___________ Daycare/ School Cost ______________________ ___________ Daycare/ School Cost If yes, due date? _________________________ Employment Information: ____________________________________________ __________________________________________ Your Employer’s Name Spouse’s Employer’s Name ____________________________________________ __________________________________________ Your Employer’s Address Spouse’s Employer’s Address ____________________________________________ __________________________________________ Your Employer’s City, State Zip Spouse’s Employer’s City, State ZIP ________________________ _______________ ________________________ ____________ Position How long? Position How long? $____________ $____________ $____________ Wkly gross pay commissions bonuses $____________ $___________ $____________ Wkly gross pay Employer health Insurance available yes No commissions bonuses Employer health Insurance available yes No Real Estate Information (please use additional page if needed): Do you and/or your spouse currently own any real estate? No yes If yes, please answer questions below. 1. _______________________________________________________________________________________ Street $________________ Mortgage Balance City, State, Zip County Deeded to H/W/Joint $_____________ ____________________________________________________ Mthly payment Mortgage Company name, address 2. _______________________________________________________________________________________ Street $________________ Mortgage Balance City, State, Zip County Deeded to H/W/Joint $_____________ ____________________________________________________ Mthly payment Mortgage Company name, address Below, list any liens, 2nd mortgages, Home Equity loans, or lines of credit on any of the properties listed above. Reference property by number from above (please use additional page if needed). ____ __________ __________ __________________________________________________ _________ No. Balance Lien Holder/Financial Institution name, address ____ __________ __________ __________________________________________________ _________ No. Balance Lien Holder/Financial Institution name, address ____ __________ __________ __________________________________________________ _________ No. Balance Lien Holder/Financial Institution name, address ____ __________ __________ __________________________________________________ _________ No. Balance Lien Holder/Financial Institution name, address Payment Payment Payment Payment H/W/Joint H/W/Joint H/W/Joint H/W/Joint Bank Information (please use additional paper if needed): (Checking, Savings, Money Market, Christmas Club, etc.) __________________________ __________________ _________________ __________________ Banking Institute Account # H/W/Joint/Other __________________________ __________________ _________________ __________________ Banking Institute Account # H/W/Joint/Other __________________________ __________________ _________________ __________________ Banking Institute Account # H/W/Joint/Other Checking/Savings Checking/Savings Checking/Savings Retirement/Pension Information (please use additional page if needed): (IRAs, 401(k), 403(b), Annuity, TIAA/CREF, Savings Plan) ____________________________ _____________ __________________ _________________ Financial Institute Account # Value H/W/Joint/Other ____________________________ _____________ __________________ _________________ Financial Institute Account # Value H/W/Joint/Other ____________________________ _____________ __________________ _________________ Financial Institute Account # Value H/W/Joint/Other Vehicles (please use additional page if needed): _____ _____________ _______________ $____________ $_____________ ___________________ Year Make Model Payment Balance Owed Titled: H/W/Joint/Other _____ _____________ _______________ $____________ $_____________ ___________________ Year Make Model Payment Balance Owed Titled: H/W/Joint/Other _____ _____________ _______________ $____________ $_____________ ___________________ Year Make Model Payment Balance Owed Titled: H/W/Joint/Other Debts (please use additional paper if needed): ________________________________________________ __________________ $________ $_______ Creditor Name, Address Debt owned by H/W/J Payment Balance ________________________________________________ __________________ $________ $_______ Creditor Name, Address Debt owned by H/W/J Payment Balance ________________________________________________ __________________ $________ $_______ Creditor Name, Address Debt owned by H/W/J Payment Balance ________________________________________________ __________________ $________ $_______ Creditor Name, Address Debt owned by H/W/J Payment Balance ________________________________________________ __________________ $________ $_______ Creditor Name, Address Debt owned by H/W/J Payment Balance
