(PLEASE COMPLETE FORM AND MAKE AN APPOINTMENT)
POST-DISSOLUTION DATA FORM
Smith, Paulson, O’Donnell & Associates, P.L.C.
201 West 7th Street
Monticello, MN 55362
(763) 295-2107
(763) 295-5165 Fax
It is important that you fill out this questionnaire as completely as possible. Your attorney will be in a better position to answer questions you may have concerning your domestic situation.
We will also need a number of documents from you to complete your matter. Please see the list on Page 5. These documents should accompany this questionnaire when it is returned to our office or as soon as you can get them to us.
Thank you for choosing Smith, Paulson, O’Donnell & Associates!
Gregory V. Smith, Gerald S. Paulson,
Patrick M. O’Donnell, Meredith J. Boudrie
Date of Interview: ______
Referred by: ______
INFORMATION ABOUT YOURSELF Date:______
Name: ______Age: ______
(First) (Middle) (Last)
Address: ______
County ______
Telephone: ______home ______work ______other
Is it o.k. to leave a message at these numbers? ______
All other names previously known by (including maiden): ______
Date of birth: ______
Length of Minnesota Residency: ______
Ethnicity: ______
INFORMATION ABOUT YOUR FORMER SPOUSE (IF KNOWN)
Name: ______Age: ______
(First) (Middle) (Last)
Address: ______
County ______
Telephone: ______home ______work ______other
All other names previously known by (including maiden): ______
Date of birth: ______
Length of Minnesota Residency: ______
Ethnicity: ______
INFORMATION ABOUT PRIOR MARRIAGE
Prior marriage information: Date Married: ______
Date Divorced: ______
What is the nature of the present problem? ______
______
______
______
______
______
______
______
______
______
______
______
If child support or child custody is at issue, please complete the following:
INFORMATION ABOUT CHILDREN
Full Name DOB Resides With SSN Of this Marriage?
Is custody of the minor child(ren) contested? Y N
What is the current custody and parenting time designated in the divorce decree? ______
______
______
Is the Custody and Parenting Time schedule being followed by both parties: ______
Is there an Order for child support in place? Y N
Do you have children born or adopted of your present marriage? Y N
Are you receiving/paying any money for support of children or former spouse? ______
Number of children/spouses: ______
Amount paid/received per month: ______
Arrearages: ______
EMPLOYMENT
SELF FORMER SPOUSE
Name of Employer ______
Address of Employer ______
______
Job Title ______
Length of Employment ______
Income (Gross) ______
OTHER INCOME/EMPLOYMENT BENEFITS
SELF FORMER SPOUSE
Public Assistance (AFDC/GA) ______
Unemployment/Worker’s Comp. ______
Interest Income ______
Dividend Income ______
Social Security Benefits for ______
Party or Child(ren)
Bonus ______
Expense Reimbursement ______
Per Diem Compensation ______
Other ______
MEDICAL/DENTAL INSURANCE
Do you have medical and/or dental insurance available to you and the child(ren) either privately or through your employer? Check any of the following that apply and fill out the monthly expense:
______Health Insurance Only
______Includes Dental and/or Vision
______Provided by your employer and/or union: Individual Cost: $______
Family Cost: $ ______
______Provided by spouse’s employer and/or union: Individual Cost: $______
Family Cost: $______
______Purchased privately: Individual Cost: $______
Family Cost: $______
Do you or your former spouse (if known) receive public assistance or medical assistance? ______
REQUESTED DOCUMENTS:
1. COPIES OF YOUR THREE MOST RECENT PAYSTUBS, LISTING YEAR TO DATE FIGURES.
- A COPY OF YOUR JOINT OR INDIVIDUAL INCOME TAX RETURN, BOTH STATE AND FEDERAL FOR THE PAST YEAR.
3. ANY COURT ORDERS RELATING TO YOUR DISSOLUTION OF MARRIAGE AND/OR CHILD SUPPORT/CUSTODY.
4. A LIST OF YOUR MONTHLY EXPENSES.
Smith, Paulson, O’Donnell & Associates, P.L.C.
October 2011
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