Mediation Intake Form Lorain Road North Olmsted, OH Phone: Fax:
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1 Full Name s Maiden Name Home Address Home Phone No. Pager or Cell No. address What County do you reside in? How long have you lived there? Social Security No. Birth Date Employer Employer Address Employer Address Number of Marriages Business Phone No. Occupation/Position Length/Employment Earnings Duffy & Associates Copyright 2009 Page 1
2 Payroll Deductions Level/Education Children s Names Date of Birth Living With State the places and dates where the child(ren) have lived during the past five years and the name and current address of the person with whom the child(ren) lived during that period. Do you anticipate a dispute over custody of minor child(ren)? Any prior litigation concerning the custody of child(ren)? Any pending court proceedings? Is wife now pregnant? Date of Marriage Place of Marriage Presently living with spouse Date of Separation Either party interested in reconciliation? Do you have plans to relocate? If so, relocation date: Duffy & Associates Copyright 2009 Page 2
3 Duffy & Associates Copyright 2009 Page 3
4 Name of Institution Bank Accounts (Checking, Savings, Money Market, CDs) Type of Account How Titled Account Number Amount on Deposit Name Business Interests (Closely-held Corporate Interests) Joint Ventures, Partnerships, Sole Proprietorships Type of Business Percentage of Ownership Orig. Amt. Invested Date Acquired Value Life Insurance Company Type of Coverage Face Amount Policy Number Insured Beneficiary Cash Surrender Value Loan Against Policy, if any Duffy & Associates Copyright 2009 Page 4
5 Retirement Plans (IRA s, 401K) Date(s) of Contribution(s) Amt(s) of Contribution(s) Present Value Account Held With Year, Make, Model Date of Purchase Motor Vehicles (Autos, Aircraft, Boats, Campers, RVs, Motorcycles) Purchase Price Down Payment Amount Financed Monthly Payment Current Loan Balance Name of Leinholder Address of Leinholder How Titled Operated by Duffy & Associates Copyright 2009 Page 5
6 Employment Benefits (Pension, Stock Option, Deferred Compensation, Profit Sharing Plans) Name of Plan Company In Whose Name Value Amount Vested Employee Contribution Address Date Purchase Real Estate (Residential, Commercial, Vacant Land,) Marital Home Purchase Price Down Payment Mortgage Balance Present Value Equity Monthly Payments Taxes To Whom Titled Name of Mortgagee Address of Mortgagee Other Second Mortgagee/Home Equity Line of Credit Address of Mortgagee Duffy & Associates Copyright 2009 Page 6
7 Occupied By Income Derived (if any) STOCKS AND BONDS Name of Issuer Type of Security Number of Shares Date Purchased Purchase Price In Whose Name Source of Funds Current Value OTHER ASSETS (Jewelry, Household Furnishings, Collectibles, Art, Guns, Coins) Description of Asset Date Acquired Present Value Duffy & Associates Copyright 2009 Page 7
8 Duffy & Associates Copyright 2009 Page 8
9 LIABILITIES Creditor Description In Whose Name Balance Due Monthly Payments MONTHLY EXPENSES Rent/House Payment Food, including lunches Clothes Childcare (specify) Car Payment Car (Gas, Oil, Repairs) Other Transportation Toothpaste, Incidentals Church, Other (specify) Newspapers, Cigarettes Duffy & Associates Copyright 2009 Page 9
10 Fees for child(ren) activities Other (specify) Utilities: Gas Oil Electric Telephone Cable Water/Sewer Other (specify) Insurance: Life Car House Hospitalization Other (specify) Medical: Doctor Hospital Dental Optometrist Prescription How did you hear about Duffy & Associates Mediation Services? Duffy & Associates Copyright 2009 Page 10
11 FINANCIAL AFFIDAVIT State of County of Being first duly cautioned, I hereby swear or affirm that I have read the foregoing document and have answered all questions fully and frankly. The answers are complete and true of my own knowledge. Signature of Signature of SWORN TO AND SUBSCRIBED before me this day of, 20. NOTARY PUBLIC Duffy & Associates Copyright 2009 Page 11
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