Case Evaluation Intake
How did you hear about The Law Firm of Victoria?
Please provide detail:
Reason For Your Consultation
Are There any pending court dates in the matter?
Yes
No
Contact Information
Name
First Name
Middle Name
Last Name
Maiden Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country in which you reside:
In the event that our firm represents you, are we able to send mail to the above home address?
Yes
No
If not, please provide an alternate secure address:
Street Address
Street Address Line 2
City
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Alabama
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District of Columbia
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State
Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Country in which you were born:
Driver's License Number:
Cellular Number
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Area Code
Phone Number
Work Number
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Area Code
Phone Number
Home Number
-
Area Code
Phone Number
Best Number we can reach you at:
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Area Code
Phone Number
What is the highest level of education you have completed?
High School
Associate's
Bachelor's
Master's
PhD
Employer:
Position:
How Long on the Job:
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gross Weekly Income:
After Tax Weekly Income:
Gross Annual Income:
Any Other Income and source:
Nearest Relative
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Opposing Party Involved
Name
First Name
Middle Name
Last Name
County in which they reside
Are they known by any other name
Date of Birth
-
Month
-
Day
Year
Date
Country in which they were born
Are you and the other party residing at the same address?
Yes
No
If not, please provide separation date:
-
Month
-
Day
Year
Date
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's License Number
Social Security Number
Cellular Number
-
Area Code
Phone Number
Home Number
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
What is the highest level of education they have completed?
High School
Associate's
Bachelor's
Master's
PhD
Employer
Position
How long on the job?
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gross Weekly Income
After Tax Income
Gross Annual Income
Any Other Income and Source
Number of Previous Marriages
You
Your Spouse
Current Marriage Information
Date of Marriage
-
Month
-
Day
Year
Date
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Country
Reason for Divorce
Have there been any previous divorce from this marriage?
Yes
No
If yes, in which country?
Date
-
Month
-
Day
Year
Date
By Whom
Are there any Personal Protection Orders against you?
Yes
No
Are there any Personal Protection Orders against the other party?
Yes
No
Minor Children Born to the Marriage
Name
Social Security Number
Name
Social Security Number
Name
Social Security Number
Name
Social Security Number
Name
Social Security Number
Other Children? If yes, Number
How are the "best interests of the child/children" served regarding custody? (Who should have custody and why?
If you and the other party have agreed on custody, describe the agreement:
Health Care Insurance
Name of Health Care Insurance Provider for Children:
Policy, group or contract number:
Through which parent:
First Name
Last Name
Physical Description of Client
Eye Color
Hair Color
Height
Weight
Race
Distinguishing scars/tattoos
Physical Description of Other Party
Eye Color
Hair Color
Height
Weight
Race
Distinguishing scars/tattoos
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