The Narris Law Office

Divorce Intake Form

CLIENT INFORMATION

Full legal name:______

Current address: ______Maiden Name (if applicable):

______

Current phone number: ______

Cell phone number (if different): ______

Email: ______

Social Security Number: ______

Date of birth: ______

Place of birth:

Number of prior marriages: ______Date most recent marriage ended: ______

SPOUSE INFORMATION

Is your spouse represented by an attorney?

If yes, please list the name, telephone number and address:

______

Full legal name:______

Current address: ______Maiden Name (if applicable):

______

Current phone number: ______

Cell phone number (if different): ______

Email: ______

Social Security Number: ______

Date of birth: ______

Place of birth:

Number of prior marriages: ______Date most recent marriage ended: ______

GENERAL INFORMATION:

Place of Marriage:

City ______County ______State______

Date of the Marriage ______

Date last lived together ______

Did you live together before the marriage: Yes No

If so, for how long?

CHILDREN:

Please list your children’s full name, date of birth and Social Security Number

FULL NAMEDATE OF BIRTHSSN

______

Does either spouse have other children? If so, please list their names and dates of birth:

If there are children outside of the marriage, please describe who has custody of those children and who pays support:

Please list any special issues involving the children’s medical, educational or emotional needs:

PLEASE BE SURE TO PROVIDE A COPY OF YOUR PAY STUB AS SOON AS YOU ARE ABLE AND BE SURE TO HAVE RECENT COPIES FOR EACH COURT DATE TO ATTACH TO THE FINANCIAL STATEMENT FILED WITH THE COURT

FINANCIAL INFORMATION:

Husband’s occupation:

Employer:

Monthly Gross Income (before taxes):

Monthly Net Income (after taxes):

Highest level of education:

Does Husband receive any overtime? If so, how frequent:

How long has Husband been employed in this profession?

Wife’s occupation:

Employer:

Monthly Gross Income (before taxes):

Monthly Net Income (after taxes):

Highest level of education:

Does Wife receive any overtime? If so, how frequent:

How long has Wife been employed in this profession?

Please describe any additional income received by you or your spouse:

Health issues of Husband:

Health issues of Wife:

HEALTH INSURANCE:

Is the health insurance provided through you or your spouse?

Are the children covered? Yes No

Policy holder: (Harvard Pilgrim, Blue Cross, etc.) ______

Policy number: ______

How much money do you or your spouse contribute every month towards health insurance?

Are there any regular additional medical costs for the children beyond the health insurance coverage?

DAY CARE:

Are any of the children in day care? YesNo

Provider:

Phone Number:

Annual cost of day care:

REAL ESTATE:

Do you and your spouse own a house together?

When was it purchased?

How did you put together the down payment? (was there a family gift or did you draw from a specific account?)

Purchase date: ______

Down payment: ______

Purchase price:______

Amount owed:

Estimated fair market value: (Please be advised that a professional appraisal will likely be needed if either party wants to remain in the home) ______

Has either you or your husband purchased any real property since you have separated? If yes, please describe:

Have either you or your husband received any inheritance or valuable gifts since you began to live together or since you married? If so, please describe:

VEHICLES:

Husband’s:YearMake and ModelUsed by Value Amt. Owed

Wife’s:YearMake and ModelUsed by Value Amt. Owed

VALUABLES: Please list any collections, jewelry or other valuables owned by you or your husband:

ItemEstimated Value

______

ItemEstimated Value

______

ItemEstimated Value

______

ItemEstimated Value

______

DEBTS

CreditorAcct#Amount Was this debt incurred during the marriage?

______

CreditorAcct#Amount Was this debt incurred during the marriage?

______

CreditorAcct#Amount Was this debt incurred during the marriage?

______

Creditor`Acct#Amount Was this debt incurred during the marriage?

______

BANK ACCOUNTS

Bank/institution / Acct#: ______

Address:

Type of account: (checking, savings, money market, CD, mutual fund, etc.) ______

Name on Account: ______

Current balance: ______

Bank/institution/ Acct#: ______

Address:

Type of account: (checking, savings, money market, CD, mutual fund, etc.) ______

Name on Account: ______

Current balance: ______

Bank/institution/Acct#: ______

Address:

Type of account: (checking, savings, money market, CD, mutual fund, etc.) ______

Name on Account: ______

Current balance: ______

Bank/institution/Acct#: ______

Address:

Type of account: (checking, savings, money market, CD, mutual fund, etc.) ______

Name on Account: ______

Current balance: ______

STOCKS AND BONDS:

Name of Company:______

Number of Shares:______Value: ______

Name of Company:______

Number of Shares:______Value: ______

Name of Company:______

Number of Shares:______Value: ______

Name of Company:______

Number of Shares:______Value: ______

PENSIONS, STOCK PURCHASE PLANS AND OTHER INVESTMENT ACCOUNTS:

Type of Account:(SEP, Keogh, IRA, pension, etc.) ______

Name on the account (participant):______