Intake No Children

DATE: *

Month Day Year
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) Billboard Internet

Client Info
Your Name: *

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

Month Day Year
Do You Wish to Restore Your Maiden Name? *

Yes No Undecided
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone *

Area Code Phone Number
Work Phone *

Area Code Phone Number
Cell Phone *

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

Month Day Year
Place of Marriage

Client Info Closed

Your Employment
Current Employer?
Education
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Employer Phone Number

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

Your Income Closed

Opposing Party
Opposing Party's Name Name: *

First Name Last Name
Currently Residing Together? *

Yes No
Spouse's Salary
Spouse's Date of Birth

Month Day Year
Spouse's Address

Street Address

Street Address Line 2

City State / Province

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

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Spouse's Employer's Phone Number

Area Code Phone Number
Does Spouse Wish to Restore Maiden Name? *

Yes No Undecided
Spouse's Maiden Name (if applicable)
Spouse's General Health

Opposing Party Close

Modification?
Place of Divorce
Date of Divorce

Month Day Year
Modification of Prior Order?

Alimony Other
Type of Modification:

Close Modification

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

City State / Province

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

No Yes
Property 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Property 3

Street Address

Street Address Line 2

City State / Province

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

Property Close

Assets
Do You Have Health Insurance?

Yes No
If You Have Children, Are They Covered with Health Insurance?

Yes No
Policy Holder for Health Insurance
Do You Have Dental Insurance?

Yes No
Policy Holder for Dental Insurance
Do You Have Life Insurance?

Yes No
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

Assets Close
Should be Empty:

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