Intake

DATE:*

MonthDayYear
How did you hear about us? ( Please check/ fill in so that we may thank your referral )*

Attorney (please put name below)Friend (please put name below)BillboardInternetOther

Client Info
Your Name:*

First NameLast Name
Maiden or other names (if applicable)*
How long have you lived in Florida?*
Date of Birth*

MonthDayYear
Do You Wish to Restore Your Maiden Name?*

YesNoUndecided
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
General Health
Last 4 of Your Social
What is Your Desired Outcome in This Matter?*
Date of Marriage

MonthDayYear
Place of Marriage

Client Info Closed

Your Employment
Current Employer?
Education
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
Job Type?
Monthly Gross?
Military Service? Please give details
Other:

Your Income Closed

Opposing Party
Opposing Party's Name Name:*

First NameLast Name
Currently Residing Together?*

YesNo
Spouse's Salary
Spouse's Date of Birth

MonthDayYear
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Education
Spouse's Employer
Nature of Job
Spouse's Phone

Area CodePhone Number
Military Service? Please give details
Spouse's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Employer's Phone Number

Area CodePhone Number
Does Spouse Wish to Restore Maiden Name?*

YesNoUndecided
Spouse's Maiden Name (if applicable)
Spouse's General Health

Opposing Party Close

Modification?
Place of Divorce
Date of Divorce

MonthDayYear
Modification of Prior Order?

Child SupportTimesharingAlimonyOther
Type of Modification:
Childs Name, Monthly Support Currently Paid

Close Modification

Children
CHILD 1:
CHILD 1 Lives with Whom?:
CHILD 1 Date of Birth

MonthDayYear
CHILD 1 Place of Birth
CHILD 2:
CHILD 2 Lives with Whom?:
CHILD 2 Date of Birth

MonthDayYear
CHILD 2 Place of Birth
Add more children: Name, Lives with Whom, Date of Birth, Place of Birth-1 per line
Who do you believe should have majority timeshare?
Do You believe there will be a dispute over timeshare?

Children Close

Debts
Account 1
Balance Account 1
Is any part of Account 1 non-maritial?
(incurred prior to marriage or after separation)
Account 2
Balance Account 2
Is any part of Account 2 non-maritial?
(incurred prior to marriage or after separation)
Account 3
Balance Account 3
Is any part of Account 3 non-maritial?
(incurred prior to marriage or after separation)
Account 4
Balance Account 4
Is any part of Account 4 non-maritial?
(incurred prior to marriage or after separation)
More: List Account Name, Balance and non-maritial portion if applicable

debts close

Property
Property 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Market Value of Residence
Mortgage
More than 1 Property

NoYes
Property 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Property 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Details of Market Value and Mortgages on Other Properties

Property Close

Assets Close
Should be Empty: