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
- 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
- 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:
- 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
- Place of Divorce
- Date of Divorce
  
  MonthDayYear
- Modification of Prior Order?
  
  Child SupportTimesharingAlimonyOther
- Type of Modification:
- Childs Name, Monthly Support Currently Paid
- 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?
- 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
- 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
- Do You Have Health Insurance?
  
  YesNo
- If You Have Children, Are They Covered with Health Insurance?
  
  YesNo
- Policy Holder for Health Insurance
- Do You Have Dental Insurance?
  
  YesNo
- If You Have Children, Are They Covered with Dental Insurance?
  
  YesNo
- Policy Holder for Dental Insurance
- Do You Have Life Insurance?
  
  YesNo
- If You Have Children, Are They Covered with Life Insurance?
  
  YesNo
- Policy Holder, Type and Amount of Life fnsurance
- Have You Received a Personal Injury or Worker's Comp Settlement During the Marriage, if yes, How much?
- Has Your Spouse a Personal Injury or Worker's Comp Settlement During the Marriage, if yes, How much?
- Auto: Who Owns?
- Year, Make, Model, Condition
- Cost-Value
- Auto: Who Owns?
- Year, Make, Model, Condition
- Cost-Value
- Auto: Who Owns?
- Year, Make, Model, Condition
- Cost-Value
- Should be Empty: