Soc. Sec. No.:
Date of Birth:
State of Birth
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:
Do you have a Will?
do you wish it to be reviewed?
If so, please return a copy of the Will with this completed form
How did you hear about our office?
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.)
Spouse's Name:
Spouse's Soc. Sec. No.:
Spouse's Address:
Spouse's Date of Brith:
Spouse's State of Birth:
Spouse's Phone:
Spouse's Fax:
Spouse's E-mail:
Spouse's Drivers License Number
Is spouse represented by counsel in this matter?
Spouse's Attorney:
Spouse's Attorney Address:
Attorney Phone:
Attorney Fax:
Spouse's Employer's Name (if any):
Spouse's Employer's Address:
Date of Employment:
Spouse's Occupation:
Spouse's Salary:
Spouse's Payment Schedule:
Date of Marriage:
Place of Marriage:
Please provide a marriage certificate
Are you and your spouse currently living together?
If not, then Date of Separation:
Do you have an interest in reconciliation?
To the best of your knowledge, does your spouse want reconciliation?
Do you want your name changed back to your maiden name? (if applicable)
Describe the circumstances that caused your separation:
Will your spouse sign a Consent to divorce?
CHILDREN'S INFORMATION (from this marriage):
Child 1 Name:
Child 1 Soc. Sec. No.:
Child 1 Date of Birth:
Living With:
Child 2 Name:
Child 2 Soc. Sec. No.:
Child 2 Date of Birth:
Child 2 Living With:
Child 3 Name:
Child 3 Soc. Sec. No.:
Child 3 Date of Birth:
Child 3 Living With:
Child 4 Name:
Child 4 Soc. Sec. No.:
Child 4 Date of Birth:
Child 4 Living With:
Currently pregnant?
if yes, Due Date:
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 here:
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, please describe support information here
If you have any documentation from previous cases related to this case that involve the same parties/children, please return copies of all documents in your possession along with this questionnaire as soon as possible.
Supporting 1:
Supporting 2:
Supporting 3:
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