INITIAL CLIENT INTAKE SHEET DISSOLUTION

Size: px

Start display at page:

Download "INITIAL CLIENT INTAKE SHEET DISSOLUTION"

Alexis Allen
5 years ago
Views:

1 INITIAL CLIENT INTAKE SHEET DISSOLUTION CLIENT FULL NAME: SSN: Address: DOB: County: Length at Address: Place of Birth City: State: County: Mailing Address: Same as above Occupation: Employer: Income Hourly Rate Per Hour: No. Hours/Wk Salary Monthly Salary Length of Residence in State: Length of Residence in County: Second Occupation: Second Employer Name: Second Income Hourly Rate Per Hour: No. Hours/Wk Telephone HOME: WORK: CELL: FAX: PAGER: Number of Previous Marriages: Last Marriage Ended by: Death Divorce Date of Divorce or Death: If Divorce, County of Dissolution: SPOUSE FULL NAME: Salary Monthly Salary Government Support: Education Years Completed HIGH SCHOOL: COLLEGE: POST GRADUATE STUDY: Race: Member of Armed Forces? YES NO SSN: Address: DOB:

2 County: Length at Address: Place of Birth City: State: County: Mailing Address: Same as above Occupation: Employer: Income Hourly Rate Per Hour: No. Hours/Wk Salary Monthly Salary Length of Residence in State: Length of Residence in County: Telephone HOME: WORK: CELL: FAX: PAGER: Number of Previous Marriages: Last Marriage Ended by: Death Divorce Date of Divorce or Death: If Divorce, County of Dissolution: CURRENT MARRIAGE: Date: SEPARATION DATE: MAIDEN NAME: FORMER NAME: Restore Name to: Second Occupation: Second Employer: Second Income Hourly Rate Per Hour: No. Hours/Wk Salary Monthly Salary Government Support: Education Years Completed HIGH SCHOOL: COLLEGE: POST GRADUATE STUDY: Race: Member of Armed Forces? YES NO City Where Married: County Where Married: Marriage license obtained in what City:

3 CHILDREN OF THIS MARRIAGE FULL NAME DATE OF BIRTH SSN CITY, COUNTY AND STATE OF BIRTH CHILD CURRENTLY RESIDING WITH: Who has actual physical custody of the minor child(ren) at this time? Wife Husband Both With whom and where have the child(ren) resided for the last 60 days? Where have the child(ren) resided for the last 6 months? Who do you feel is best suited to have custody of the minor child(ren): Wife Husband Both Has there ever been any litigation concerning custody of these child(ren) in Missouri or in any other state? YES NO Have there ever been any discussions or agreement concerning child support or maintenance? YES NO UCCJEA REQUIREMENT For each child, list the places the child has resided during the last five years, and name and addresses of the persons with whom the child has lived during such periods. FROM TO ADDRESS WITH WHOM PARENTING PLAN INFORMATION Weekend Schedule (frequency, days & time): Week Day Schedule (days & times): HEALTH INSURANCE Who Carries Child(ren): Mother Father Name of Provider: Identification No: Monthly Cost to Insure Child(ren): DAYCARE COSTS Name of Daycare: Address of School: Cost per Month per Child:

4 CHILDREN FROM PREVIOUS MARRIAGES (whether by birth or adoption DO NOT include children of a previous marriage who have not been adopted by you or your spouse) FULL NAME DATE OF BIRTH SSN CITY, COUNTY AND STATE OF BIRTH CHILD CURRENTLY RESIDING WITH: I. INCOME A. Employer Address: STATEMENT OF INCOME AND EXPENSES OF SSN: Check if unemployed PAID: (check one) Hourly Wage rate per hour: Average hours per week: Average monthly wages: $ Gross Salary/Wages and Commission Each Pay Period: Average Monthly Wages: Paid: Weekly Bi-Weekly Semi-Monthly Monthly Number of Dependents Claimed: Number of Exemptions Claimed: PAYROLL DEDUCTIONS: FICA (Social Security Tax) Federal Withholding Tax State Withholding Tax Medicare Union Dues Health Insurance OTHER DEDUCTIONS: Salary Average Monthly Salary: $ TOTAL DEDUCTIONS EACH PAY PERIOD NET TAKE HOME PAY EACH PAY PERIOD B. ADDITIONAL INCOME from Rentals, Dividends and Business Enterprises, Social Security, AFDC, VA Benefits, Pensions, Annuities, Bonuses, Commissions and all other sources (give monthly average and list sources of income)

5 Bonuses Draw Pension/Retirement Annuity Interest Income Dividend Income Trust Income Social Security Overtime/Commission Workers Compensation Public Aid/Food Stamps Rental Income Business Income Royalty Fellowship/Stipends Unemployment Disability Payments Other Income Child Support received for children not of this proceeding Maintenance received from third party AVERAGE MONTHLY TOTAL C. TOTAL AVERAGE NET MONTHLY INCOME D. Total gross income from tax returns for each of the last 3 calendar years: YEAR: YEAR: YEAR: II. EXPENSES required to maintain the previous standard of living stated on a MONTHLY average HOMEOWNERS EXPENSES Rent Mortgage Second Mortgage Real Estate Taxes Insurance Lot Rent Association Fees Maintenance of Home Lawn Service Pest Control Veterinarian and General Pet Care

6 TOTAL HOME EXPENSES UTILITIES Natural Gas Water Electricity Telephone Trash Service Cable/Satellite Sewer Cellular Phone/Pager Internet Provider TOTAL UTILITIES EXPENSES CLEANING AND LAUNDRY Housekeeper Laundry Dry Cleaning Cleaning Products TOTAL CLEANING AND LAUNDRY MEDICAL EXPENSES General Care Dental Care Health Insurance Prescription Drugs Over the Counter Drugs Eye Care Mental Health Care TOTAL MEDICAL EXPENSES PERSONAL HYGIENE & BEAUTY Hair Cuts/Perm Manicures Pedicures Massage Personal Products TOTAL PERSONAL HYGIENE & BEAUTY EXPENSES

7 AUTOMOBILE AND TRANSPORTATION Loan Payment Gasoline Routine Maintenance Personal Property Tax Auto Insurance License Inspection Parking Fees Toll Fees Taxi Fees Subway Fees TOTAL AUTOMOBILE EXPENSES GENERAL LIVING Food Clothing Household Furnishings Linen, Towels, etc. Life Insurance TOTAL GENERAL LIVING EXPENSES BOOKS, NEWSPAPERS, PERIODICALS Newspaper Magazines Books Periodicals Tuition Fees Seminars TOTAL BOOKS, NEWSPAPERS & PERIODICAL EXPENSES RECREATION, FITNESS, ENTERTAINMENT Movies Videos Music Sporting Events League Fees Club Membership Vacation/Travel Dining Out

8 Sports Equipment/Apparel TOTAL RECREATION, FITNESS, ENTERTAINMENT EXPENSES CHARITABLE CONTRIBUTIONS Organizations Schools Personal Church United Way TOTAL CHARITABLE CONTRIBUTIONS EXPENSES SPECIAL OCCASION EXPENSES Birthdays Weddings, Showers & Gifts Christmas Child Care TOTAL SPECIAL OCCASION EXPENSES CREDIT CARDS & OTHER INSTALLMENTS American Express VISA Mastercard Discover Card Other Bank Cards Store Credit Cards TOTAL CREDIT CARD & OTHER INSTALLMENT EXPENSES CHILD SUPPORT PAID BY CLIENT FOR CHILDREN NOT INVOLVED IN THIS PROCEEDING: ALIMONY OR MAINTENANCE PAID TO FORMER SPOUSE: OTHER MISC EXPENSES

9 TOTAL OTHER MISC. EXPENSES OTHER EXPENSES Disability Insurance Dental Insurance Vision Insurance TOTAL OTHER EXPENSES MINOR AND/OR DEPENDENT CHILDREN: Health Insurance Medical Including Co-Pay Dental Vision Psychological Other Health Educational Childcare Extraordinary Expenses Food Clothing TOTAL CHILDREN S EXPENSES OTHER CHILDREN S EXPENSES Prescription Drugs Recreation Laundry and Dry Cleaning Barber and Beauty Shop School Lunches Lessons TOTAL OTHER CHILDREN S EXPENSES TOTAL AVERAGE MONTHLY EXPENSES

10 PROPERTY WORKSHEET CLIENT: Please read before completing this form. The attached form is provided to our clients in order to assist you more efficiently in completing your list of assets. Please describe the items of personal property with enough detail that it will not be confused with a similar item of property, i.e. Flowered Blue Chair not just Chair. Please try to list each item separately and avoid lumping items together, i.e. if you just put Bedroom Furniture, it will be difficult for us to match it to your spouse s list if they itemize each piece. Each column must be completed with all the information asked for on the form. It is important that you list all items of property even if they are in your spouse s possession and even if the item was acquired before the marriage or after the separation. If you fail to list an item, it may cause a dispute later and possible result in loss of that item to your spouse. Non-marital (NM) property constitutes property that was purchased prior to the marriage or was a gift during the marriage to the respective spouse or acquired by inheritance by the respective spouse. Marital (M) property is any and all property obtained during the period of the marriage excluding the above. Property obtained after separation is still considered marital (M) property. Please be sure you list all outstanding debts on the page marked Debts and include the balance remaining and who should assume this obligation. Current market value is that amount that a willing buyer would pay a willing seller, example would be a rummage sale/auction price. It does not mean the purchase price or replacement price. Listing of personal items can be time-consuming and sometimes frustrating, however, if you will complete this form accurately, it will help all of us and will expedite your case.

11 PROPERTY WORKSHEET CLIENT: Description of Item REAL ESTATE: Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) VEHICLES: BANK ACCOUNTS: STOCKS & BONDS: BOATS/MOTORS/ TRAILERS:

12 Description of Item HOUSEHOLD FURNISHINGS: Living Room: (Couch) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Loveseat) (Rocker) (Recliner) (Piano) (Coffee Table) (Fireplace Equipment) (Books) (Bookcase) (Lamps) (Desk) (Chairs) (End Tables) (Rugs) (Curtains) (Pictures) (Photos) (Hall Tree) (Wall Shelf) (Fans) (Clock) (Stereo) (Television) (VCR) (Telephone) (Answering Machine) (Entertainment Center)

13 Description of Item HOUSEHOLD FURNISHINGS: Bedrooms: (Bed) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Mattress/Box Springs) (Vacuum) (Dressers) (Bureaus) (Mirrors) (Night Stands) (Rocker) (Cedar Chest) (Sheets) (Blankets) (Comforters) (Closet Racks) (Shoe Racks) (Books) (Bookcase) (Lamps) (Desk) (Chairs) (Rugs) (Curtains) (Pictures) (Photos) (Fans) (Clocks) (Stereo) (Television) (VCR) (Telephone)

14 (Answering Machine) Description of Item Bathrooms: (Linens) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Hairdryer) (Scales) (Towels) (Medicine Cabinet) (Accessories) (Cabinets) (Clothes Hampers) (Mirrors) (Medical Devices) (Medical Supplies) (Telephone) (Closet Racks) (Shoe Racks) (Books) (Bookcase) (Lamps) (Desk) (Chairs) (Rugs) (Curtains) (Pictures) (Photos) (Fans) (Clocks)

15 (Stereo) (Television) (VCR) Description of Item HOUSEHOLD FURNISHINGS: Kitchen: (Dishes) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Cutlery) (Silverware) (Microwave) (Microwave Stand) (Refrigerator) (Freezer) (Dishwasher) (Stove) (Pots/Pans) (Cabinets) (Bakers Rack) (Glassware) (Ironing Board) (Coffee Maker) (Knife Set) (Bread Maker) (Toaster) (Electric Can Opener) (Table/Chairs) (Bakeware) (Washer) (Dryer)

16 (Bar Stools) (Crock Pot) (Pressure Cooker) (Blender) (Mixer) (Books) (Bookcase) (Lamps) (Desk) (Chairs) (End Tables) Description of Item HOUSEHOLD FURNISHINGS: Kitchen: (continued) (Rugs) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Curtains) (Pictures) (Photos) (Hall Tree) (Wall Shelf) (Fans) (Clocks) (Stereo) (Television) (VCR) (Telephone) (Answering Machine) (Entertainment Center)

17 Dining Room: (Table & Chairs) (Bureau) (Crystal) (China) (Table Linens) (Sewing Machine) (Silverware) (China Cabinet) (Hutch) (Books) (Bookcase) (Lamps) (Desk) (Chairs) Description of Item Dining Room: (continued) (End Tables) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Rugs) (Curtains) (Pictures) (Photos) (Hall Tree) (Wall Shelf) (Fans) (Clocks) (Stereo) (Television)

18 (VCR) (Telephone) (Answering Machine) (Entertainment Center) JEWELRY: (Watches) (Rings) (Necklaces) (Earrings) (Broaches) (Gems) Description of Item TOOLS, LAWN & GARDEN EQUIPMENT: (Riding Mower) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Push Mower) (Blower) (Chain Saw) (Weed Eater) (Table Saw)

19 (Battery Charger) (Air Compressor) (Hand Tools) (Power Tools) (Tool Box) (Ladder) (Shelves) (Fans) (Picnic Table) (Swing Set) (Porch Swing) (Garden Hose) (Sprinklers) (Wheelbarrow) (Lawn Ornaments) (Bird Bath) (Flower Pots) (BBQ Grill) (Hot Tub) (Spa Supplies) (Pool Supplies) (Plants) (Lighting) (Furniture) (Patio Speakers) (Telephone) (Stereo) Description of Item TOOLS, LAWN & GARDEN EQUIPMENT (continued) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM)

20 FIREARMS & SPORTS EQUIPMENT: (Bikes) (Skis) (Volleyball/Net) (Tennis Racket) (Bowling Ball) (Treadmill) (Rowing Machine) (Stairmaster) (Exercise Bike) (Weights) (Fishing Equipment) (Golf Equipment) (Diving Gear) (Tent) (Lanterns) (Camping Gear) (Bow & Arrow) (Pistols) (Rifles) (Other)

21 Description of Item BOOKS, ART OBJECTS & COLLECTIBLES: (Antiques) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Coins) (Stamps) (Figurines) (Paintings) (Dolls) (Baseball Cards) (Other) STORAGE: (Luggage) (Trunks) (Antiques) (Furniture) (Photos) (Other) Description of Item OFFICE EQUIPMENT: (Computer) Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM) (Scanner)

22 (Printer) (Copier) (Fax) (Digital Camera) (File Cabinet) (Desk) (Chair) (Bookcase) OTHER: LIVESTOCK & ANIMALS: FARM EQUIPMENT: Description of Item BUSINESS INTEREST & EQUIPMENT: Who has Possession? Your opinion of the Current Market Value Should Item be Awarded to? Do you claim Item is Non- Marital? (NM)

23 INSURANCE POLICIES: IRA: CERTIFICATES OF DEPOSIT: RETIREMENT & PENSION PLANS: OTHER INVESTMENTS: DEBTS/CREDITORS: Is Debt Secured by Property? Balance Owed Monthly Payment Who Should Pay Debt??

24 OTHER:

INITIAL CLIENT INTAKE SHEET PATERNITY

INITIAL CLIENT INTAKE SHEET PATERNITY CLIENT NAME: SSN: Address: DOB: Mailing Address (if different from above): Place of Birth: County: Length of Residence in State: Alimony or Maintenance Paid to / Received