DIVORCE CONSULTATION SHEET

MARITAL FACT SHEET FOR

CLIENT INFORMATION

Name: (first, middle, last)
Maiden name (if applicable):
Age:
Date of Birth:
City and state of birth:
Social security number:
Race:
Of Hispanic Origin?
If yes, specify:
State the total number of years of formal education you have had:
Please list any institutions attended after high school, if applicable: Name of Institution / Years of Attendance / Degree Obtained/Major Course of Study Place where mail can be delivered to you confidentially:
Street Address
City, State, Zip Code
Home phone number

EMPLOYMENT

Name of your employer:
Occupation (job title):
Address of employer:
Street Address
City, State, Zip Code
Home phone number
How long have you been employed by your current employer?
How often are you paid? (Check one):	Weekly Bimonthly Monthly

Your gross (before deductions) employment income per pay period:
Your net (after deductions) income per pay period:
If you have any income other than from your chief employment, state:

From whom such income is received:
Occupation (job title):
Gross amount:
Net amount:
If you are not employed, state:
Name of your last employer:
Occupation (job title):
The dates you were employed:
The amount of income you received from your last employment, during the last year you were employed:

YOUR SPOUSE

Name: (first, middle, last)
Maiden name (if applicable):
Age:
Date of Birth:
City and state of birth:
Social security number:
Race:
Of Hispanic Origin?
If yes, specify:
State the total number of years of formal education spouse has:
Please list any institutions attended after high school, if applicable: Name of Institution / Years of Attendance / Degree Obtained/Major Course of Study Address at which your spouse currently resides:
Street Address
City, State, Zip Code
Home phone number

SPOUSE'S EMPLOYMENT

Name of spouse's employer:
Spouse's Occupation (job title):
Address of Spouse's employer:
Street Address
City, State, Zip Code
Home phone number
How long has your spouse been employed by his/her current employer?
How often is your spouse paid? (Check one):	Weekly Bimonthly Monthly

Your spouse's gross (before deductions) employment income per pay period:
Your spouse's net (after deductions) income per pay period:
If your spouse has any income other than from his/her chief employment, state:

From whom such income is received:
Gross amount:
Net amount:
If your spouse is not employed, state:
Name of your spouse's last employer:
Occupation (job title):
The dates your spouse was employed:
The amount of income your spouse received from his/her last employment, during the last year he/she was employed:

MARITAL INFORMATION

Date of your marriage:
If separated from your spouse, the date of separation:
City, county, and state in which you were married:
If you were previously married, how many times?
As to each previous marriage of yours, state whether the marriage was ended by (check one):	Death Divorce
If you have minor children by a previous marriage, state:
The name of the person who has custody of the children:
The child support provisions in the Judgment of Dissolution of Marriage:

If you were previously married, how many times?
As to each previous marriage of yours, state whether the marriage was ended by (check one):	Death Divorce
If you have minor children by a previous marriage, state:
The name of the person who has custody of the children:
The child support provisions in the Judgment of Dissolution of Marriage:

If you and your spouse previously filed for divorce against the other, state:
The date the divorce was filed:
The county in which the divorce was filed:
The attorney who represented you in the divorce proceeding:
The attorney who represented your spouse in the divorce proceeding:
If you have previously consulted with an attorney about marital problems regarding this marriage, state the name of the attorney and approximate date of the conversation:

If you and your spouse, or one of you, received either psychological or marital counseling for this marriage, state:
Name and address of counselor:
Who attended the counseling sessions (check one):	Husband Wife Both
The approximate time period (weeks or months) in which there was counseling, and approximately how many counseling sessions there were:

Check any of the following that describe your marital problems:
Financial
Incompatibility
Lack of Communication
Lack of Interest
Infidelity
Drinking problems
Physical Abuse
Mental Abuse
Lack of Common Interests
Frequent and Ongoing Arguments
Late Hour or Absence from Residence
Disagreements regarding your children
Other, Please Describe:

CHILDREN
As to each child born to you and your spouse, state the following:
Name Age Date of Birth Who Has Custody (You/Spouse)

Describe any unusual health or psychological problems of any of the children named above,
and if the child is under a physician's care, state the physician's name and telephone number:

MONEY ON DEPOSIT

As to any monies on deposit in any financial institution, state the following (if there is
more than one such account, please provide the information on a separate sheet):

Joint Accounts
Checking
Name of Institution:
Account Number:
Approximate Current Balance:
Savings
Name of Institution:
Account Number:
Approximate Current Balance:

Accounts in husband's name alone:
Checking
Name of Institution:
Account Number:
Approximate Current Balance:
Savings
Name of Institution:
Account Number:
Approximate Current Balance:

Accounts in wife's name alone:
Checking
Name of Institution:
Account Number:
Approximate Current Balance:
Savings
Name of Institution:
Account Number:
Approximate Current Balance:

As to any certificates of deposit or other money deposits, state the following
(if there is more than one such account, please provide the information on a separate sheet):

Joint:
Name of Institution:
Name of Fund:
Account Number:
Approximate Principal Balance:

Husband's:
Name of Institution:
Name of Fund:
Account Number:
Approximate Principal Balance:

Wife's:
Name of Institution:
Name of Fund:
Account Number:
Approximate Principal Balance:

REAL ESTATE

Primary Marital Residence

As to the primary marital residence, please state:
The name(s) of the individual(s) who title is vested in:
If the property is held in tenancy by the entirety or joint tenancy:

Purchase date:
Purchase price:
Approximate of current value:
Mortgage Institution
Balance of mortgage:
Interest Rate:
Account Number:

Amount of taxes and insurance, or state, if these amounts are included in the monthly mortgage payments:
Approximate balance of any second mortgage:

Other Real Estate

If title to real estate is held in trust, please state:

Name of bank or other institution holding title in trust:
Location of property, including county and state:

As to all real estate, whether title is held in trust or not, state the following information on beneficial interest in the trust owned:

The name(s) of the individual's) who title is vested in:
If the property is held in tenancy by the entirety or joint tenancy:

Purchase date:
Purchase price:
Approximate of current value:
Mortgage Institution
Balance of mortgage:
Interest Rate:
Account Number:

Amount of taxes and insurance, or state, if these amounts are included in the monthly mortgage payments:
Approximate balance of any second mortgage:

Other Real Estate

If title to real estate is held in trust, please state:

Name of bank or other institution holding title in trust:
Location of property, including county and state:

As to all real estate, whether title is held in trust or not, state the following information on beneficial interest in the trust owned:

The name(s) of the individual(s) who title is vested in:
If the property is held in tenancy by the entirety or joint tenancy:

Purchase date:
Purchase price:
Approximate of current value:
Mortgage Institution
Balance of mortgage:
Interest Rate:
Account Number:

Amount of taxes and insurance, or state, if these amounts are included in the monthly mortgage payments:
Approximate balance of any second mortgage:

AUTOMOBILES

Driven by wife:
Year:
Make:
Approximate date acquired:
Balance owed:
Monthly payments:
Finance Company:
Driven by Husband:
Year:
Make:
Approximate date acquired:
Balance owed:
Monthly payments:
Finance Company:
Other:
By whom is the automobile usually used:
Year:
Make:
Approximate date acquired:
Balance owed:
Monthly payments:
Finance Company:
Other:
By whom is the automobile usually used:
Year:
Make:
Approximate date acquired:
Balance owed:
Monthly payments:
Finance Company:

STOCKS AND BONDS

If you own any stocks or bonds, state the following (if you own more than one, please describe on a separate sheet):

Name of corporation:
Number of shares:
Approximate value of each share, or total value of all shares:

OTHER ASSETS OVER $500

If either you or your spouse has any assets that were acquired during the marriage, but not by gift or inheritance, and excluding household goods, which have an amount over $500.00 (describe each asset (e.g. boat) and state:

Asset Date Acquired Current Value Who Has Possession (You/Spouse)

Do you now own an asset with a value of more than $500.00 which you owned before the marriage and which has not been placed in joint ownership between you and your spouse?
Yes
If yes, describe the asset, the date acquired and its approximate value:

Does your spouse now own an asset with a value of more than $500.00 which your spouse owned before the marriage and which has not been placed in joint ownership between you and your spouse?
Yes
If yes, describe the asset, the date acquired and its approximate value:

Have you inherited any asset valued at more than $500.00 which asset has not been placed in ownership with your spouse?
Yes
If yes, describe the asset, the date inherited and its approximate value:

Has your spouse inherited any asset valued at more than $500.00 which asset has not been placed in ownership with you?
Yes
If yes, describe the asset, the date inherited and its approximate value:

Have you acquired any asset valued at more than $500.00 by gift from anyone?
Yes
If yes, describe the asset, the date acquired, its approximate value, and whether it has it been placed in ownership with your spouse:

Has your spouse acquired any asset valued at more than $500.00 by gift from anyone?
Yes
If yes, describe the asset, the date acquired, its approximate value, and whether it has it been placed in ownership with you:

PENSION PLANS

If you have a pension planer other deferred-income plan (ie. employee stock option plan or profit-sharing plan) whether vested or not, state the name and address of the employer providing the plan and how long you have been or were employed by said employer:

If your spouse have a pension plan or other deferred-income plan (ie. employee stock option plan or profit-sharing plan) whether vested or not, state the name and address of the employer providing the plan and how long your spouse has been or were employed by said employer:

HEALTH INSURANCE

Are you covered under a health insurance policy provided by (check one): Your Employer Private Plan Your Spouse's Employer Not Covered Please state the following with regards to your coverage:
Name and address of the Health Insurance Company:
Cardholder Name:
Plan Number:
Group Number:
Amounts of Co-Payments or Deductibles:

Is your spouse covered under a health insurance policy provided by (check one): Your Employer Private Plan Your Spouse's Employer Not Covered Please state the following with regards to your coverage:
Name and address of the Health Insurance Company:
Cardholder Name:
Plan Number:
Group Number:
Amounts of Co-Payments or Deductibles:

Are your children covered under a health insurance policy provided by (check one): Your Employer Private Plan Your Spouse's Employer Not Covered/NA Please state the following with regards to your coverage:
Name and address of the Health Insurance Company:
Cardholder Name:
Plan Number:
Group Number:
Amounts of Co-Payments or Deductibles:

LIFE INSURANCE

Are you covered under a life insurance policy provided by (check one): Your Employer Private Plan Your Spouse's Employer Not Covered/NA Please state the following with regards to your coverage:
Name and address of the Health Insurance Company:
Plan Number:
Amount of Death Benefit:
Beneficiary:

Is your spouse covered under a life insurance policy provided by (check one): Your Employer Private Plan Your Spouse's Employer Not Covered/NA Please state the following with regards to your spouse's coverage:
Name and address of the Health Insurance Company:
Plan Number:
Amount of Death Benefit:
Beneficiary:

DEBTS

As to each debt owed by either you or your spouse, state:

Name of creditor:
Address of creditor:
Whose name appears on the account:
Date the debt was incurred:
Who incurred the debt:
Approximate balance:
Monthly payment amount:
Describe item purchased, or the reason the debt was incurred:

Name of creditor:
Address of creditor:
Whose name appears on the account:
Date the debt was incurred:
Who incurred the debt:
Approximate balance:
Monthly payment amount:
Describe item purchased, or the reason the debt was incurred:

Name of creditor:
Address of creditor:
Whose name appears on the account:
Date the debt was incurred:
Who incurred the debt:
Approximate balance:
Monthly payment amount:
Describe item purchased, or the reason the debt was incurred:

Name of creditor:
Address of creditor:
Whose name appears on the account:
Date the debt was incurred:
Who incurred the debt:
Approximate balance:
Monthly payment amount:
Describe item purchased, or the reason the debt was incurred:

AGREEMENTS OF YOU AND YOUR SPOUSE

If you and your spouse have made any agreements regarding custody of the children, visitation, financial matters, or disposition of property upon a divorce, state what those agreements are:

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