LAW OFFICE OF PATRICIA E. TICHENOR, P.L.L.C.
19490 Sandridge Way, Suite 370A
Leesburg, Virginia 20176
(703) 669-6700 Telephone
(703) 669-6701 Facsimile
Email: OR
Divorce Questionnaire
(Uncontested with Minor Children)
TODAY’S DATE:
Click here to enter text.
Part I. General Information About Marriage
Date of Marriage: Click here to enter text.
Place of Marriage: Click here to enter text. (city) Click here to enter text. (county) Click here to enter text.(state)
Date of Separation: Click here to enter text.
(Date of Separation Defined: Date at which time at least one of your formed the intention to permanently separate from the other- and since then neither of you have resumed marital relations)
Who formed the intention to separate: ☐Husband ☐ Wife ☐ Both
When was such intention formed: Click here to enter text.
Minor Children: ☐ YES ☐ NO (if Yes, please do not forget to answer Part IV below)
Address of Marital Residence (last address where you cohabitated as husband and wife): Click here to enter text.
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Part II. Information Regarding Husband
Full Legal Name: Click here to enter text.
Address: Click here to enter text.
Home Phone Number: Click here to enter text.
Cell Phone Number: Click here to enter text.
Social Security Number: Click here to enter text. Date of Birth: Click here to enter text.
Place of Birth (state only): Click here to enter text.
Driver’s License Number: Click here to enter text.
Highest Level of Education Completed:
☐high school ☐1 year of college ☐2 years of college ☐3 years of college
☐4 years of college ☐5+ years of education
Occupation: Click here to enter text.
Employer Name: Click here to enter text.
Address: Click here to enter text.
Work Phone #: Click here to enter text.
What number marriage is this marriage for Husband: Click here to enter text.
Do you hold any licenses (such as fishing license, hunting license, teaching license, law license, etc.) ☐YES ☐NO
If Yes, please indicate the kind of licenses you hold: Click here to enter text.
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Part III. Information Regarding Wife
Full Legal Name: Click here to enter text.
Full Maiden Name: Click here to enter text.
Address: Click here to enter text.
Home Phone Number: Click here to enter text.
Cell Phone Number: Click here to enter text.
Social Security Number: Click here to enter text. Date of Birth: Click here to enter text.
Place of Birth (state only): Click here to enter text.
Driver’s License Number: Click here to enter text.
Highest Level of Education Completed:
☐high school ☐1 year of college ☐2 years of college ☐3 years of college
☐4 years of college ☐5+ years of education
Occupation: Click here to enter text.
Employer Name: Click here to enter text.
Address: Click here to enter text.
Work Phone #: Click here to enter text.
What number marriage is this marriage for Wife: Click here to enter text.
Do you hold any licenses (such as fishing license, hunting license, teaching license, law license, etc.) ☐YES ☐NO
If Yes, please indicate the kind of licenses you hold: Click here to enter text.
Wife’s Attorney (If Applicable): Click here to enter text.
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Part IV. Information Regarding Children:
Please provide the following information for each child (even if over the age of 18):
1. Name: Click here to enter text. Date of Birth: Click here to enter a date.
Social Security Number: Click here to enter text.
2. Name: Click here to enter text. Date of Birth: Click here to enter a date.
Social Security Number: Click here to enter text.
3. Name: Click here to enter text. Date of Birth: Click here to enter a date.
Social Security Number: Click here to enter text.
4. Name: Click here to enter text. Date of Birth: Click here to enter a date.
Social Security Number: Click here to enter text.
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Part V. Health Insurance Information:
(NOTE:Alternatively, please provide insurance card to Ms. Tichenor or Ms. Safi so they can make a copy of card- in such case, you do not need to fill out the information below)
Health Insurance Holder: ☐Husband ☐ Wife
Health Insurance Carrier: Click here to enter text.
Identification No: Click here to enter text.
If different Identification numbers, please provide each ID number for each individual
Click here to enter text.
Group Number: Click here to enter text.
Mailing Address: Click here to enter text.
Telephone Number: Click here to enter text.
Do you have a separate carrier for vision/dental insurance? ☐ YES ☐ NO
If Yes, please attach vision/dental insurance card or provide the following information:
Vision/Dental Insurance Carrier: Click here to enter text.
Identification No: Click here to enter text.
If different Identification numbers, please provide each ID number for each individual
Click here to enter text.
Group Number: Click here to enter text.
Mailing Address: Click here to enter text.
Telephone Number: Click here to enter text.
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