Soc. Sec. No.:
Home Address:
Date of Birth:
State of Birth:
Home Phone:
Work Phone:
Fax Number:
Driver's License Number:
Dates of residency at current address:
List any previous residences in the past five (5) years, and dates resided in each:
Employer's Name (if any):
Employer's Address:
Job Title:
Nature of Job:
Date of Employment:
Salary: $
Payment Schedule:
Have you retained any other attorneys on this matter prior to coming to this office?
If yes, please provide name, date retained, and reason to discontinue service:
Opposing Name:
Opposing Soc. Sec. No.:
Opposing Address:
Opposing Date of Birth:
Opposing State of Birth:
Opposing Phone:
Opposing Fax:
Opposing E-mail:
Opposing Driver's License Number:
Is spouse represented by counsel in this matter?
If yes, complete the following: Spouse's Attorney Name:
Spouse's Attorney Address:
Spouse's Attorney Phone:
Spouse's Attorney Fax:
Spouse's Employer's Name:
Spouse's Employer Address:
Spouse's Date of Employment:
Spouse's Occupation:
Spouse's Salary:
Spouse's Payment Schedule:
CHILDREN'S INFORMATION (from this marriage/relationship):
Child 1 Name:
Child 1 Soc. Sec. No.:
Child 1 Place of Birth
Child 1 Date of Birth:
Child 1 Living With:
Child 2 Name:
Child 2 Soc. Sec. No.:
Child 2 Place of Birth:
Child 2 Date of Birth:
Child 2 Living With:
Child 3 Name:
Child 3 Soc. Sec. No.:
Child 3 Place of Birth:
Child 3 Date of Birth:
Child 3 Living With:
Child 4 Name:
Child 4 Soc. Sec. No.:
Child 4 Place of Birth:
Child 4 Date of Birth:
Child 4 Living With:
UCCJEA Information
Custodian 1 Name:
Custodian 1 Address:
Dates Resided with Custodian 1:
Custodian 2 Name:
Custodian 2 Address:
Dates Resided with Custodian 2:
Custodian 3 Name:
Custodian 3 Address:
Dates Resided with Custodian 3:
Custodian 4 Name:
Custodian 4 Address:
Dates Resided with Custodian 4:
Have you participated as a party, witness or any other capacity in other litigation or custody proceedings, including divorce, separate maintenance, child neglect, dependency or guardianship, concerning custody or visitation of any child subject to this proceeding?
If Yes, please describe:
Do you have any information of any custody or visitation proceeding currently pending in a court of this or any other state concerning any child subject to this proceeding:
If Yes, please describe when it started and all details:
Do you have any knowledge of any support order issued by a court of this or any other state concerning any child subject to this proceeding?
If Yes to the above, please describe:
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