Domestic New Client Questionnaire
This form is used in order to collect information to file a case on your behalf
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Full Name (First Middle Last)
Maiden Name
Date of Birth
MM
/
DD
/
YYYY
Place of Birth
Present Street Address (Street, City, State, and Zip)
How long have you lived at the above address
Telephone Number
Email Address
Current Employer Name
Employer's Address (Street, City, State, and Zip
Employer's Phone Number
Monthly Take Home Pay
Job Title
Spouse"s or Significant Other's Name (First, Middle, Last)
Spouse's or Significant Other's Date of Birth
MM
/
DD
/
YYYY
Spouse's or Significant Other's Place of Birth
Spouse's or Significant Other's Place of Birth
Spouse's or Significant Other's Address (Street, City, State, Zip)
Spouse's or Significant Other's Phone Number
Spouse's or Significant Other's Email Address
Spouse's or Significant Other's Email Address
Spouse's or Significant Other's Employer Name
Spouse's or Significant Other's Employer Address (Street, City, State, and Zip)
Spouse's or Significant Other's Employer Telephone Number
Spouse's or Significant Other's Monthly Take Home Pay
Date of Marriage
MM
/
DD
/
YYYY
Place of Marriage (City, County, State)
Number of Prior Marriages (Husband)
Number of Prior Marriages (Wife)
Presently Separated if so when was the separation?
List Names and Date of Birth's of all Children born of this marriage/relationship
Who are the children currently residing with?
Please list all addresses where the children have resided the past 5 years
Please list the names and addresses of all adults who have lived with the children in the past 5 years
Do the children have health insurance?
Clear selection
If yes, who provides insurance for the children?
If you or your spouse have OTHER children in the home please list their names and dates of birth.
What vehicles do you and your spouse own? (please include VIN numbers)
What vehicles do you and your spouse own? (please include VIN numbers)
What car you driving?
Do you wish to continue driving it during the pendency of the divorce?
Clear selection
If yes, provide make, model and VIN number
What is your Educational Background (Highest level of Education Completed)
If a divorce is granted, should the wife’s maiden name or prior name be restored?
Clear selection
If so what name should be used?
Please provide any additional information you I should know concerning the problems in your marriage. Please let me know if there are any issues of domestic violence.
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