Client Data Sheet: Divorce

Law Office of Melissa D. Rowcliffe, P.C.

CLIENT DATA SHEET

DIVORCE INFO
Date:*

MonthDayYear
Date
Mobile Phone:*
Format: (000) 000-0000.
Home Phone:*
Format: (000) 000-0000.
Email Address:*
example@example.com
CLIENT >>
1. Name:*
Age:*
2. Address:*

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
3. How Long Have You Lived at this Address?
4. What COUNTY Do You Currently Reside in?*
Race:
5. Date of Birth:*

MonthDayYear
Date
Place of Birth (city/state):
6. Employer:*
Job Title:
Work Address:

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
Work Phone:
Format: (000) 000-0000.
May We Call You at Work?
Work Email:
example@example.com
May We Email You at Work?
Monthly Gross Salary $:
Annual Gross Salary $:*
Length of Employment:*
Please List Any/All Education/Training:
If Military, Which Branch?
Rank:
Months in Service:
Status:

ActiveRetired
7. Social Security #:*
Driver's License (inc state):*
8. Additional Address Where You Can Be Reached:

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
Additional Phone:
Format: (000) 000-0000.
9. Level of Schooling Completed:*
10. Number of Marriages (including present):*
11. If Previously Married, How Many Marriages Ended By:
Death
Divorce:
Annulment:
SPOUSE >>
1. Spouse Name:*
Age:
2. Spouse Address:

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
3. How Long Has Other Parent Lived at this Address?
What COUNTY Does Spouse Currently Reside in?*
Race:
4. Home/Mobile Phone:*
Format: (000) 000-0000.
Email:
example@example.com
5. Date of Birth:

MonthDayYear
Date
Place of Birth (city/state):
6. Spouse Employer:
Job Title:
Work Address:

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
Monthly Gross Salary $:
Yearly Gross Salary $:
Main Work Phone:
Format: (000) 000-0000.
Length of Employment:
Please List Any/All Education/Training:
If Military, Which Branch?
Rank:
Months in Service:
Status:

ActiveRetired
7. Social Security #:
Drivers License (inc state):
8. Additional Address and/or Phone Number Where Spouse Can Be Reached?

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
Additional Phone:
Format: (000) 000-0000.
9. Level of Schooling Completed:
10. Number of Marriages (including present):
11. If Previously Married, How Many Marriages Ended By:
Death
Divorce:
Annulment:
MARRIAGE >>
1. Date of Marriage:*

MonthDayYear
Date
Total Years of Marriage:*
2. Marriage Location (city, state & county):
3. Your/Wife's Maiden Name:*
4. Do You Wish to Change Your Name?

YesNoN/A
5. Date of Separation:

MonthDayYear
Date
Is This Marriage Common Law?

YesNo
6. Are You/Wife Currently Pregnant?*

YesNo
Have You Seen a Marriage Counselor?

YesNo
If Yes, Please Provide Counselor Info:

Name

Street Address Line 2

City & CountyState / Province

Postal / Zip Code
Counselor Phone:
Format: (000) 000-0000.
Have You and Your Spouse Attempted Reconciliation?

YesNo
If No, Would You Like to Attempt Reconciliation?

YesNo
Designate As Appropriate if Your Marital Difficulties Involve Any of the Following:

Drugs/Alcohol AbuseEmotional AbuseConfinement in a Mental Institution (for at least 3 years)Financial DisputeYour InfidelitySpouse's InfidelityNon-Cohabitation (for at least 3 years)Physical ViolenceReligious DifferencesOther
Have You or Your Spouse Ever Used/Currently Using Any Illicit Drugs including Marijuana, THC or Delta 8?*

YesNo
If Yes, Explain:
Are You or Your Spouse Taking Any Medications that are Not Prescribed By a Doctor?*

YesNo
If Yes, Explain:
Are You or Your Spouse Taking Any Medications for a Mental Health Condition?*

YesNo
If Yes, Explain:
LIVING CHILD(REN) OF THIS MARRIAGE >>
Child 1 - Full Name:
Child 1 - SS #:
Child 1 - Gender
Child 1 - Place of Birth (city, state & county):
Child 1 - Date of Birth:

MonthDayYear
Date
Child 1 - Currently Resides with:
Child 2 - Full Name:
Child 2 - SS #:
Child 2 - Gender
Child 2 - Place of Birth (city, state & county):
Child 2 - Date of Birth:

MonthDayYear
Date
Child 2 - Currently Resides with:
Child 3 - Full Name:
Child 3 - SS #:
Child 3 - Gender
Child 3 - Place of Birth (city, state & county):
Child 3 - Date of Birth:

MonthDayYear
Date
Child 3 - Currently Resides with:
Child 4 - Full Name:
Child 4 - SS #:
Child 4 - Gender
Child 4 - Place of Birth (city, state & county):
Child 4 - Date of Birth:

MonthDayYear
Date
Child 4 - Currently Resides with:
Are the Child(ren) Covered by Health Insurance?

YesNo
If Yes, Provide Info (carrier & which parent provides coverage):
Are the Child(ren) Covered by Dental Insurance?

YesNo
If Yes, Provide Info (carrier & which parent provides coverage):
Where Has the Child(ren) Been Living For the Past 5 Years?
Location 1 - Where, From-To & With Whom
Location 2 - Where, From-To & With Whom
Location 3 - Where, From-To & With Whom
Has There Ever Been a Custody Fight Regarding the Child(ren)?

YesNoN/A
Has There Ever Been a Protective Order Issued/Applied For the Child(ren)?

YesNoN/A
COMMUNITY PROPERTY >>
List All Real Property Owned/Purchased DURING the Marriage (including County where property is located):
Property Location 1:*
Property Location 2:
List All Vehicles Owned/Purchased DURING the Marriage (including year, make & model):
Vehicle 1:*
Year, Make & Model
Loan/Lease?*

YesNo
Vehicle 2:
Year, Make & Model
Loan/Lease?

YesNo
Vehicle 3:
Year, Make & Model
Loan/Lease?

YesNo
Vehicle 4:
Year, Make & Model
Loan/Lease?

YesNo
List All Retirement Accounts Acquired DURING the Marriage:
Account 1:
Bank Name & Account Type
Approximate Balance $:
Account 2:
Bank Name & Account Type
Approximate Balance $:
Account 3:
Bank Name & Account Type
Approximate Balance $:
Account 4:
Bank Name & Account Type
Approximate Balance $:
SEPARATE PROPERTY >>
List All Real Property Owned/Purchased PRIOR to the Marriage (including County where property is located):
Property Location 1:
Property Location 2:
List All Vehicles Owned/Purchased PRIOR to the Marriage (including year, make & model):
Vehicle 1:
Year, Make & Model
Loan/Lease?

YesNo
Vehicle 2:
Year, Make & Model
Loan/Lease?

YesNo
Vehicle 3:
Year, Make & Model
Loan/Lease?

YesNo
List All Retirement Accounts Acquired PRIOR to the Marriage:
Account 1:
Bank Name & Account Type
Approximate Balance $:
Account 2:
Bank Name & Account Type
Approximate Balance $:
Have You Ever Visited an Attorney Prior to Today?*

YesNo
Have You Ever Discussed this Case with Another Attorney?*

YesNo
If Yes, Please Provide Attorney Info:
Attorney Name
Attorney Address:

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
Attorney Phone:
Format: (000) 000-0000.
Has Your Spouse Ever Discussed ANY Case with the Law Office of Melissa D. Rowcliffe?*

YesNo
Who Did You Hear About the Law Office of Melissa D. Rowcliffe?
If Referral, Who Provided Referral?
RETAINER QUOTES FOR DIVORCE CASES ARE VALID FOR 90 DAYS
Should be Empty:

CLIENT >>

SPOUSE >>

MARRIAGE >>

LIVING CHILD(REN) OF THIS MARRIAGE >>

COMMUNITY PROPERTY >>

SEPARATE PROPERTY >>

RETAINER QUOTES FOR DIVORCE CASES ARE VALID FOR 90 DAYS