New Client Information Form

FORT IRWIN LEGAL ASSISTANCE DIVISION

DIVORCE QUESTIONAIRE

rev. 09/05/2014

Privacy Act Statement

Authority: 10 USC 3012

Principal Purposes: To screen clients for eligibility for legal assistance services; to gather personal information in order to determine if conflicts of interests exist.

Routine Uses: None.

Disclosure is Voluntary, but failure to supply this information may preclude the provision of legal services. Completing this form, in and of itself, does not establish an attorney / client relationship.

ð NEW DIVORCE ÿ LEGAL SEPARATION ÿ EXISTING CASE

GENERAL INFORMATION

(1) YOUR FULL NAME: ________________________________________________________ Last 4 SSN ____________

FIRST MIDDLE LAST

(2) Home Ph: _______________ Work Ph _______________ Cell Ph ________________ Email ____________________

(3) Address: _______________________________ City _________________ State ___________ Zip _______________

(4) Military Member Y__ N__ Military Unit: _____________________________ ð Active Duty ð National Guard ð Reserve

(5) YOUR SPOUSE'S FULL NAME: _______________________________________________ Last 4 SSN ____________

FIRST MIDDLE LAST

(6) Home Ph: _______________ Work Ph _______________ Cell Ph ________________ Email ____________________

(7) Address: ________________________________ City _________________ State ___________ Zip _______________

(8) Military Member Y__ N__ Military Unit: _____________________________ ð Active Duty ð National Guard ð Reserve

(9) Are you or your spouse planning to move, PCS, or ETS within the next 12 months? ð YES ð NO

If yes, When _______________ Where________________________

(10) Primary issue of divorce today: ð Divorce Information (State_____) ð File for divorce/legal separation (State_____)

ð Respond to a filed divorce (State_____) ð Issue with Existing Divorce (State_____)

(11) Have you (ð YES ð NO) or your spouse (ð YES ð NO) retained a civilian attorney to represent you for this divorce?

(12) Is there anything urgent or time sensitive related to your case? Has a court given you a deadline to complete anything or told you to be anywhere on a certain date or time? ________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

MARRIAGE INFORMATION

(as applicable)

(13) Date Of Marriage: ________/_______/______ State of Marriage: ______________________

Date Of Separation: ________/_______/______ Date Of Divorce: ________/_______/______

Date Arrived to California: ________/________/_______

(14) Have you or your spouse already filed for Divorce, Legal Separation or Annulment?

ð YES ð NO If yes, Who ________________ When _______________ Where______________

Interviewer Notes: _________________________________________________________________________________

________________________________________________________________________________________________

STOP HERE FOR EXISTING DIVORCE CASES. CONTINUE FOR NEW DIVORCE AND LEGAL SEPARATION

FORT IRWIN LEGAL ASSISTANCE DIVISION

DIVORCE QUESTIONAIRE

rev. 09/05/2014

(15) Does your spouse agree to divorce? ð YES ð NO

(16) Do you and your spouse agree on custody of children and division of property? ð YES ð NO

RESIDENCY

(17) Have you (ð YES ð NO) or your spouse (ð YES ð NO) lived in San Bernardino County, California for the past 6 months?

(18) In which state do you claim legal residency? ________________ Do you file taxes in this state? Yes__ No__

(19) Do you and your spouse intend to physically separate (if applicable)? Yes__ No__ N/A __ If so, when? ____________

MINOR CHILDREN OF MARRIAGE

(do not list step-children, unless they have been adopted)

ð Check here if Wife is currently pregnant

ð Check here if there are NO MINOR CHILDREN

(20) Name Living With

________________________________ ð You ð Spouse ð Other: __________________________

(21) Have your children lived in San Bernardino County, California for the past 6 months? ð YES ð NO

(22) Are there any custody or guardianship Orders covering any of the children? ð YES ð NO

(23) Is there a pre-existing Child Support or Spousal Support Order? ð YES ð NO

Interviewer Notes:_________________________________________________________________________________

________________________________________________________________________________________________

Interviewer’s Name ____________________________