Divorce and Legal Separation Intake Form

DIVORCE & SEPARATION INTAKE FORM
Date

MonthDayYear
Date
MWYEMCJCSJRS
DivorceLegal Separation
Your Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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

CityState / 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
WorkHome
Marital Information
Date of Marriage*
Date of Separation*
NoYes
If Yes, County of filing
NoYes
If Yes, Attorney’s name
NoYes
If Yes, Maiden Name
NoYes
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?
NoYes
If No, in what County and State did they previously reside?
Should be Empty: