DIVORCE & SEPARATION INTAKE FORM
Date
/
Month
/
Day
Year
Date
Attorney (Office use only)
MWY
EMC
JCS
JRS
Attorney
Divorce
Legal Separation
Your Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
How Long?
*
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
Social Security Number (Last 4)
Employer
Employer Address
Other Party’s Information
Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
Social Security Number
Employer
Employer’s Address
Where to serve other party?
Work
Home
Marital Information
Date of Marriage
*
Date of Separation
*
Has the case already been filed?
No
Yes
If Yes, County of filing
Does Other Party have an attorney?
No
Yes
If Yes, Attorney’s name
Will maiden name be restored?
No
Yes
If Yes, Maiden Name
Is a Protective Order needed?
No
Yes
If Yes, Why is a Protective Order needed?
Marital Property and Debt
Item
Rows
Description
Titled in Whose Name?
Who has Possession?
Value
Is Item at Issue?
Marital Home
Vehicle #1
Vehicle #2
Credit Card #1
Credit Card #2
Credit Card #3
Credit Card #4
Credit Card #5
Jewelry
Savings Accounts
Checking Accounts
Stocks, Bonds, CDs
Pension Retirement
Other Real Estate
Life Insurance
Inheritance
Other Real Estate
Furniture
Other
Children
Rows
Name
Date of Birth
SSN
Gender
Highest Education Level
In what County and State do the children currently reside?
Have they resided in the current state and county for the preceding six months?
No
Yes
If No, in what County and State did they previously reside?
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