Stallard & Bellof Client Intake Form

Opposing Party Information
Opposing Party's Name: *

First Name Middle Name Last Name Suffix
Address

Street Address

Street Address Line 2

City State

Zip Code Country
County of Residence
Cell Phone Number
Home Phone Number (if different from above)
Opposing Party's E-mail
Date of Birth

Month Day Year
Employer:
Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Occupation:
Work Schedule/Hrs:
Pay Rate
Frequency of Pay

Weekly Twice per month Every other week Monthly
Gross Income:
Net Income:
Other Income(rent, dividends, trust, disability):
Military Status

Active Duty Military Reserve Retired Never in the military
Attorney, if known:

Children *

The opposing party and I have a child/children together No children with opposing party

Children of the Relationship
Name of Child 1:
Date of Birth

Month Day Year
Name of Child 2:
Date of Birth

Month Day Year
Name of Child 3:
Date of Birth

Month Day Year
Name of Child 4:
Date of Birth

Month Day Year
Name of Child 5:
Date of Birth

Month Day Year
State the current custodial arrangements and any preferences or agreements regarding custody of the children.

Cohabitation *

The opposing party and I have never resided together The opposing party and I currently reside together The opposing party and I formerly resided together but no longer do
Marriage *

The opposing party and I have never been married The opposing party and I have never been married, but we own property together The opposing party and I are currently married The opposing party and I were married at one time, but are now divorced
Date of Marriage

Month Day Year
Place of Marriage

Street Address

Street Address Line 2

City State / Province

Country
Date You Began Living in Different Residences ("Date of Separation")

Month Day Year
Do you wish to return to a previously used name?

Yes No
Full Name To Reassume

First Name Middle Name Last Name
Date of Divorce

Month Day Year

Student Loans:
Please list ALL held by EITHER party,

regardless of whose name is on it
Student Loan 1 Company
Obligor:

Me Spouse
Balance as of Date of Separation (current if not separated)
Student Loan 2 Company
Obligor:

Me Spouse
Balance as of Date of Separation (current if not separated)
Student Loan 3 Company
Obligor:

Me Spouse
Balance as of Date of Separation (current if not separated)
Student Loan 4 Company
Obligor:

Me Spouse
Balance as of Date of Separation (current if not separated)

Outstanding Tax Debt:
Tax Year
Remaining Tax Owed
Tax Year
Remaining Tax Owed
Tax Year
Remaining Tax Owed

Business Property
Does either party own a business?
Business Name:
Owned By

Me Opposing Party Both
Type of Business:
Owner's Title:
Date of Business Acquired:

Month Day Year
Percent Ownership Interest:
Current Fair Market Value of the Business:
Business Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Real Property
Please list ALL owned by EITHER party,

regardless of whose name is on it
Real Property Address 1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Names on Deed
Purchase Price
Fair Market Value as of Date of Separation (current if not separated)
Date of Purchase

Month Day Year
Names on Mortgage
Mortgage Balance as of Date of Separation (current if not separated)
Monthly Payment
Annual Property Taxes
Real Property Address 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Names on Deed
Purchase Price
Fair Market Value as of Date of Separation (current if not separated)
Date of Purchase

Month Day Year
Names on Mortgage
Mortgage Balance as of Date of Separation (current if not separated)
Monthly Payment
Annual Property Taxes
Real Property Address 3

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Names on Deed
Purchase Price
Fair Market Value as of Date of Separation (current if not separated)
Date of Purchase

Month Day Year
Names on Mortgage
Mortgage Balance as of Date of Separation (current if not separated)
Monthly Payment
Annual Property Taxes
Real Property Address 4

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Names on Deed
Purchase Price
Fair Market Value as of Date of Separation (current if not separated)
Date of Purchase

Month Day Year
Names on Mortgage
Mortgage Balance as of Date of Separation (current if not separated)
Monthly Payment
Annual Property Taxes

Bank and Investment Accounts
Please list ALL owned by EITHER party,

regardless of whose name is on it
Bank/Investment Financial Institution 1
Name(s) on the account
Type of Account
Balance as of Date of Separation (current if not separated)
Bank/Investment Financial Institution 2
Name(s) on the account
Type of Account
Balance as of Date of Separation (current if not separated)
Bank/Investment Financial Institution 3
Name(s) on the account
Type of Account
Balance as of Date of Separation (current if not separated)
Bank/Investment Financial Institution 4
Name(s) on the account
Type of Account
Balance as of Date of Separation (current if not separated)
Bank/Investment Financial Institution 5
Name(s) on the account
Type of Account
Balance as of Date of Separation (current if not separated)
Bank/Investment Financial Institution 6
Name(s) on the account
Type of Account
Balance as of Date of Separation (current if not separated)

Automobiles, Motorcycles, RV's, Trailers, Watercraft, Airplanes
Please list ALL owned by EITHER party,

regardless of whose name is on it

	Year,Make,Model	Names on Titles	Date Acquired	Date of Separation Fair Market Value	Date of Separation Loan Balance of Loan	Who drives?
Vehicle1
Vehicle2
Vehicle3
Vehicle4
Vehicle5
Vehicle6
Vehicle7
Vehicle8

Credit Cards:
Please list ALL held by EITHER party,

regardless of whose name is on it
Credit Card 1
Name on the account
Balance as of Date of Separation (current if not separated)
Credit Card 2
Name on the account
Balance as of Date of Separation (current if not separated)
Credit Card 3
Name on the account
Balance as of Date of Separation (current if not separated)
Credit Card 4
Name on the account
Balance as of Date of Separation (current if not separated)
Credit Card 5
Name on the account
Balance as of Date of Separation (current if not separated)
Credit Card 6
Name on the account
Balance as of Date of Separation (current if not separated)

Other Loans:
Please list ALL held by EITHER party,

regardless of whose name is on it
Loan Name
Name on the account 1
Balance as of Date of Separation (current if not separated)
Loan2 Name
Name on the account 1
Balance as of Date of Separation (current if not separated)
Loan3 Name
Name on the account 1
Balance as of Date of Separation (current if not separated)
Loan4 Name
Name on the account 1
Balance as of Date of Separation (current if not separated)

Any other asset or debt you want to mention that wasn't requested previously

What outcome are you seeking? (i.e., house, children, restraining orders, share of retirement)
List any questions you would like to discuss.
Initial Consultation Non-Engagement Notice *

I have been scheduled for an initial consultation with Stallard & Bellof, PLLC, Attorneys at Law. I understand that no further obligation is incurred by either party as a result of the consultation and that Stallard & Bellof, PLLC has not yet been retained to represent me. If and when Stallard & Bellof, PLLC is retained in this matter, a formal agreement for legal services will be executed between the parties.
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Client Information

Opposing Party Information

Children of the Relationship

Separate Property - property currently owned by either spouse but acquired before marriage

Inheritance Received During the Marriage

Gifts Received During the Marriage

Retirement Accounts

Student Loans:

Outstanding Tax Debt:

Business Property

Real Property

Bank and Investment Accounts

Automobiles, Motorcycles, RV's, Trailers, Watercraft, Airplanes

Please list any of the following: Precious Metals, Jewelry, Collectibles, Antiques, Other Assets.

Credit Cards:

Other Loans: