Domestic Relations Intake Form

Domestic Relations Intake Form
CONFIDENTIALITY: The information you enter in this questionnaire is confidential. The information will not be disclosed to anyone outside of this office, except in the course of rendering legal services on your behalf or as otherwise provided by law.
Today’s Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Source:
Area of Law:
Please answer all questions completely.

1. CLIENT
Name:
Address:
City:
State:
Zip:
Mailing Address (if different):
Email Address:
example@example.com
Home Phone:
Cell Phone:
Work Phone:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Soc. Sec. No.:
Name of nearest relative:
Relationship:
Address of nearest relative:
City:
State:
Zip:
Phone of nearest relative:
County resided in last 90 days:
State resided in last 6 months:
Any pending lawsuits against anyone:
Date of Marriage:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Marriage:
Please list City, County and State
Any previous marriages?
If so, when and where?
Have you retained any other attorneys on this matter prior to coming to this office? If yes, please provide name, date retained, and reason to discontinue their services.
2. CLIENT EMPLOYMENT INFORMATION
Employer Name:
Employer Address:
City:
State:
Zip:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years of Service:
Occupation:
Hourly or Salary:
Number of Pay Periods:
If hourly, average number of hours per pay period:
If hourly, hourly rate of pay:
Average number of overtime hours per pay period:
Estimated average yearly gross income:
Estimated average yearly net income:
Any deduction other than for taxes (health insurance, self-employment expenses, union dues, etc):
Any pension or retirement plans:
If YES, what are they:
Value, if known:
Does Client pay or receive child support?
Is so, how much?
Has Client ever filed for bankruptcy?
If so, when?
Are you responsible for any other children not subject to this action?
If so, list their name(s) and date of births:
3. OPPOSING PARTY' S PERSONAL INFORMATION
Name:
Address:
City:
State:
Zip:
Phone:
Email:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Soc. Sec. No.:
Name of spouse’s attorney:
County resided in last 90 days:
State resided in last 6 months:
Pending lawsuits against anyone:
4. OPPOSING PARTY' S EMPLOYMENT INFORMATION
Employer Name:
Employer Address:
City:
State:
Zip:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years of Service:
Occupation:
Hourly or Salary:
Number of pay periods:
If hourly, average number of hours per pay period:
If hourly, hourly rate:
Average number of overtime hours per pay period:
Overtime rate of pay:
Estimated average net income per pay period:
Estimated average yearly gross income:
Estimated average yearly net income:
Any deduction other than for taxes health insurance, self-employment expenses, union dues, etc:
Any pension or retirement plans:
Value, if known:
Has spouse ever filed for bankruptcy?
5. CHILDREN (IF NO CHILDREN - SKIP TO 6. REAL ESTATE) Please list children's name, dob and with whom child currently resides with:
Will there be sole custody or shared parenting?
If sole custody, who will be custodian?
If shared parenting, who is residential parent for school purposes?
Does spouse pay or receive child support?
CHILD SUPPORT WORKSHEET
Father’s gross annual income:
Mother’s gross annual income:
Other children that you pay support to?
if so, how much?
How many other children (not issue of this marriage) do you have?
How many other children does your spouse have?
Are any of the children employed?
CHILDREN’S HEALTH INSURANCE
Who provides primary coverage:
What is cost per pay period, if any:
Insurance company:
Address:
Phone number:
Policy Number:
Group Number:
Is there secondary coverage available to other spouse?:
If so, list company name, address, phone number, policy, and group number:
How will out-of-pocket costs be divided?:
DEPENDENCY EXEMPTION
Who will get exemptions for which children in whih years?:
Who will get exemptions for which children in which years?:
VISITATION
Will there be a standard order of visitation?
Will there be a customized possession schedule?
Describe possession time of the parents:
Has anyone in the household been convicted of or pled guilty to domestic violence or abuse/neglect of a family member?
PARENTING AFFIDAVIT INFORMATION - this MUST be fully completed if there are minor children. Where have the children resided for last 5 years and with whom?
Please list the child's name, dates (from-to), with whom and the address during that time frame.
Jane Doe- Jan 2017-Dec.2019-Mother- 100 Main St., Elyria, OH 44035
6. REAL ESTATE
Address of marital home:
Deed in whose name?
Date of purchase:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Purchase Price:
Down Payment:
Source of down payment:
Beginning first mortgage:
Lender:
Monthly payment:
Are taxes included?
Amount of 2 mortgage or Home Equity Line (if any):
Date of second mortgage or equity line:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Monthly payment of second mortgage or equity line:
Other liens or easements:
Date of last appraisal of property:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Value at last appraisal:
Present value:
Estimated equity:
Do you own other real estate?:
If house is to be sold, how will the bills be divided while awaiting sale and how will the net proceeds from the sale of the home be divided?
If one party is keeping the house and the mortgage is in both parties’ names, who is getting the house and how much time will the person have to refinance the mortgage and buy out the other party’s interest?
If the parties are still living together at the marital residence, how long will the person who is leaving have to vacate the residence?
AUTOMOBILES, BOATS, AIRPLANES, OTHER VEHICLES
Do any of the vehicles have equity in them?
If so, how much?
LIQUID ASSETS
List husband’s separate checking or savings accounts and balances:
List husband’s separate checking or savings accounts and balances:
List wife’s separate checking or savings accounts and balances:
List wife’s separate checking or savings accounts and balances:
List joint checking or savings accounts and balances:
List joint checking or savings accounts and balances:
LIFE INSURANCE POLICIES
Does either party possess any life insurance policies with the other named as the beneficiary?
What will the disposition of those policies be?
INHERITANCES / GIFTS
During the course of the marriage, did either party receive an inheritance or a gift meant only for them and therefore not subject to division as marital property?
If so, describe:
8. DEBTS Please list all debts, listed in your name, spouses' name and jointly.
9. Please provide a narrative of your case:
Should be Empty:

Domestic Relations Intake Form

CHILD SUPPORT WORKSHEET

CHILDREN’S HEALTH INSURANCE

DEPENDENCY EXEMPTION

VISITATION

6. REAL ESTATE

AUTOMOBILES, BOATS, AIRPLANES, OTHER VEHICLES

LIQUID ASSETS

LIFE INSURANCE POLICIES

INHERITANCES / GIFTS