Client Questionnaire



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8525 Edinbrook Crossing, Suite 105; Brooklyn Park, MN 55443

Phone: (763) 244-1002 ; Fax: (763) 244-1003; Email: stacy@

Information gathering is a vital part of managing your case and your legal costs. The information you provide is necessary to proceed and to best represent your interests. Although the form is long, please fill it out as completely and accurately as possible. As information changes, provide updated information for your file. The questionnaire is confidential and will remain in the possession of Stacy Wright Family Law & Mediation, Chtd.

• Set aside about 30 minutes to read through the questionnaire from beginning to end. Think about the information that you already have, the information that you can get easily and the information that will be more difficult to get. Plan to spend two or three hours to gather all of the information and to complete the form.

• Skip any section that does not apply to your marriage or relationship.

• If you need additional space for an answer, attach additional sheets or use the back of a page.

• If there are restrictions on how we can contact you (for instance work hours, ability to leave messages, mail, etc.) please note them on the form.

• If there are court actions that involve this relationship (OFP, Support, etc.) please provide:

• court order (if possible)

← case number

← county in which the action took place

← approximate date of the order (month and year).

• If you own real estate, call the county in which it is located to find out the legal description.

• Contact your Plan Administrator for model language if retirement assets will be divided.

• Get a copy of your Credit Report. If possible, get a copy of your spouse’s Credit Report.

• Begin to gather information. Make copies for your client file. Keep the originals in a safe place.

✓ paycheck stubs,

← bank account statements,

← credit card statements,

← credit reports,

← mortgage statements,

← retirement accounts,

← other information that you feel will be helpful.

• If you do not have access to some of the requested information, make note of it on the Client TO DO list on the last page of this questionnaire. After you have gathered the information, send copies to the law office and the copies will be added to your client file.

• Complete the budget. Make a copy for your records. Track your spending against your estimated budget. Adjust your budget as necessary.

|Marriage Information |

|Date of present marriage Date of Separation |

|Place of marriage (City__________________________, County____________, State _______) |

|Did you enter into an Antenuptial agreement? |

|Who was your attorney? |

MARITAL INFORMATION

Your Full Name: __________________________

(first, middle, last)

Former or Other Name(s):____________________

_________________________________________

Address:_________________________________ _________________________________________

_________________________________________

Mailing address __________________________ _______________________________________

New address: _____________________________

As of (date):______________________________

Soc Sec Number:______-_______-__________

Date of Birth:____/____/______ Age:______

Phone Numbers: Home__________________

Cell ___________________________________

Work _________________hours___________

E-Mail_______________________________

Preferred means to contact you_____________

Spouse’s Name: ___________________________

(first, middle, last)

Former or Other Name(s):____________________ _________________________________________

Address:_________________________________ __________________________________________________________________________________

Mailing address __________________________

________________________________________

New address: _____________________________

As of (date): ______________________________

Soc Sec Number:______-_______-___________

Date of Birth:_____/_____/_______ Age:_______

Phone Numbers: Home_____________________

Cell ___________________________________

Work _________________ hours____________

E-Mail __________________________________

Attorney Name ____________________________

General State of Health:

| | |You |Spouse |Children |

|Mental Health Counseling or Support |Diagnosis | | | |

| |Medication | | | |

| |Physician | | | |

|Alcohol or Chemical Use/Dependency |Chemical of choice | | | |

| |Treatment | | | |

|General Physical |Treatment | | | |

|(e.g. Diabetes, Asthma, Allergies, |Medication | | | |

|Cancer, etc.) |Physician | | | |

Support Obligations

List all current support paid or received by you or your spouse.

Include amounts paid since the date of separation from your spouse.

Include arrears if applicable.

Child Support:

| |Amount Paid |Amount Received |

|Child Support |Current Marriage |Former relationship(s) |Current Marriage |Former relationship(s) |

|You | | | | |

|Your Spouse | | | | |

|Spousal Maintenance |Current Marriage |Former relationship(s) |Current Marriage |Former relationship(s) |

|You | | | | |

|Your Spouse | | | | |

Are the payments listed above pursuant to a court order or voluntary?__________________________

Do you believe that voluntary payments will continue on a regular basis?_______________________

Jurisdiction and Venue:

Have you been a resident of Minnesota for more than six months?_______________________________ In which County do you live? ________________________Your Spouse?_________________________

Have you (or your spouse) ever started a divorce or legal separation proceeding before? ______________ When? Where? What was the outcome?___________________________________________________

____________________________________________________________________________________

Will you (or your spouse) be moving out of state in the near future?______________________________

Are you (or your spouse) in the military service of the United States?_____________________________

Do you (or your spouse) desire a name change at the time of the dissolution? _______________________ From______________________________________To_______________________________________

Children born or adopted during the marriage

| Child’s Name |Birthdate & Age |Social Security # |Living with? |Special Concerns Education, |

| | | | |Behavior, Physical |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Is paternity of any of the children an issue?__________________________________________________

Is any child under the jurisdiction of a juvenile court or in need of protection?______________________

Are there children or stepchildren from another relationship who may be affected by this dissolution?

Explain:_____________________________________________________________________________

Are you or your spouse currently pregnant?_______ Biological father (if known)____________________

Considering the best interests of the children, indicate who should have:

Legal Custody

Mother______ Father_______ Joint_______

Physical Custody

Mother_______ Father_______ Joint_______

Do you and your spouse agree upon:

Your child’s school? _____________ Which school district?___________________________________

Your child’s medical care?_____________ Who is your doctor/dentist?___________________________

Your child’s religious training?_____________ Which religion(s)?______________________________

Do you and your spouse have the ability to talk with each other about important or sensitive issues?_____

Does your spouse make decisions or do things that are not good for your children? __________________

____________________________________________________________________________________

Describe the parental access schedule that would work best for your family?_______________________

________________________________________________________________________________________________________________________________________________________________________

OR: Assuming you will rotate weekends with the children, what schedule works best?

Please be mindful of start and end times (e.g. until 8 pm, or Overnight until 8 am).

| |Mon |Tues |Wed |Thurs |Fri |Sat |Sun |

|Week 1 | | | | |Mom after school |Mom |Mom |

|Week 2 | | | | |Dad after school |Dad |Dad |

HOLIDAY SCHEDULE: Please note that you can add or delete holidays that are important to you

Some holidays will be alternated Even years with Mom, Odd years with Dad

Some holidays will be shared: With Mom until 2, with dad from 2-8

Some holidays will go as per your regular schedule of alternating weekends.

Some holidays will be ignored.

Think about what is important to YOUR family.

|Holiday |2013 and Odd Years |2014 and Even Years |

|Child’s Birthday | | |

|Respondent's Birthday | | |

|Petitioner's Birthday | | |

| | | |

|New Year's Eve and Day | | |

|Easter Sunday | | |

|Mother's Day |Always Mom |Always Mom |

|Memorial Day and Weekend | | |

|Father's Day |Always Dad |Always Dad |

|Fourth of July | | |

|Labor Day and Weekend | | |

|Halloween | | |

|Thanksgiving Day to Friday 9AM | | |

|Friday after Thanksgiving at 9AM | | |

|Christmas Eve | | |

|Christmas Day | | |

Do you have concerns about the safety of your children? _______________________________________

________________________________________________________________________________________________________________________________________________________________________

Have you discussed the issue of divorce with your children?____________________________________

Does your child attend a support group or counseling?_________________________________________

Would you like a referral to an agency that can provide guidance and support to your family as you go through the divorce transition?____________________________________________________________

Income Information: Attach paycheck stubs if possible. Use back of sheet if needed.

YOU

Degrees obtained:________________________ Occupation:_____________________________

Employed by:___________________________

for ___ years Hours per week:_____________

Address of Employer:_____________________

_______________________________________

Gross Salary: _____________ per ___________

Net Salary (take home)___________ per ________

Bonus: _________________________________

Deductions from gross salary:

Pension or 401(k) contribution________________

Health Insurance________________________

Union Dues____________________________

Loan__________________________________

Other__________________________________

Other__________________________________

Other source of income or potential source of income?________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

YOUR SPOUSE

Degrees obtained:________________________ Occupation:_____________________________

Employed by:___________________________

for ___ years Hours per week:_____________

Address of Employer:_____________________

_______________________________________

Gross Salary: _______________ per _________

Net Salary (take home)___________ per ________

Bonus: _________________________________

Deductions from gross salary:

Pension or 401(k) contribution________________

Health Insurance________________________

Union Dues____________________________

Loan__________________________________

Other__________________________________

Other__________________________________

Other source of income or potential source of income?________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Business Interests:

Name of Company:_________________________________________________________________

Address:__________________________________________________________________________

Phone:______________________ Service or Product:_____________________________________

Date Acquired:___________ Cost of Investment:____________ Source of Investment___________

Position Held:______________________ Other Partners:__________________________________

_________________________________________________________________________________

Stock Interest:_____________________________ Number of Shareholders:___________________

Directors/Officers:_________________________________________________________________

Additional information______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

County/State Benefits:

Welfare Benefits received by you or your spouse: County:_______________________

(check all that apply)

_____Cash grant (AFDC or MFIP) Amount______________

_____Medical Assistance

_____Minnesota Care

_____Subsidized or Sliding fee childcare assistance

_____Veterans Administration

_____Social Security for ___________________________

_____Unemployment Compensation

_____ Workers' Compensation

_____ Other, Explain_______________________________________________________________

_________________________________________________________________________________

Assets:

Use page 11 to list non-marital characteristics of any asset

Homestead Address:___________________________________________________________________

Title held by: You____ Spouse ____ Both ____ Abstract or Torrens Property?_____________________

Legal Description:_____________________________________________________________________

Date Purchased:____________________ Purchase Price:______________________________________

Monthly PITI Payment:_____________________ Property Taxes (if not included) _________________

Down Payment (amount and source) ______________________________________________________

Mortgage Balance:___________________________ Owed to: _________________________________

2nd Mortgages:____________________________ Owed to: _________________________________

Line of Credit:____________________________ Owed to: _________________________________

Market Value:___________________________ Tax assessed value: _____________________________

Source of Market Value:___________________________ Approximate Equity:____________________

Other real property: Cabin, hunting land, time share, vacation home, etc.

include legal description, purchase price, market value, amount owed and title information if known: ____________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Automobiles

|Year/Make/Model |Value |Loan Amount |Bank or lending institution |In Possession of |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Other motor vehicles such as boats, snowmobiles, motorcycles, etc.

Use page 11 to list non-marital characteristics of any asset

|Year/Make/Model |Value |Loan |Bank or lending institution |In Possession of |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Financial accounts

Checking, savings, certificates, stocks & bonds, safety deposit boxes, persons that owe you money

|Type of Account |Account number |Location (bank or institution) |Approximate value |Name(s) on Account |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Attach additional sheets if necessary.

Life Insurance

YOU

Policy No.____________________________ Company ____________________________

Type:Term___ Variable ___ Whole life___

Is this policy obtained through employment? _____________________________________

_____________________________________

Face Value of Policy:___________________ Beneficiary on this policy________________

Yearly Premium: $__________

Cash Surrender/Loan Value___________

Other Policy

Policy No.____________________________ Company ____________________________

Type: Term___ Variable ___ Whole life___

Is this policy obtained through employment? _____________________________________

_____________________________________

Face Value of Policy:___________________ Beneficiary on this policy________________

Yearly Premium: $_____________________

Cash Surrender/Loan Value______________

YOUR SPOUSE

Policy No.____________________________ Company ____________________________

Type:Term___ Variable ___ Whole life___

Is this policy obtained through employment? _____________________________________

_____________________________________

Face Value of Policy:___________________ Beneficiary on this policy________________

Yearly Premium: $__________

Cash Surrender/Loan Value___________

Other Policy

Policy No.____________________________ Company ____________________________

Type: Term___ Variable ___ Whole life___

Is this policy obtained through employment? _____________________________________

_____________________________________

Face Value of Policy:___________________ Beneficiary on this policy________________

Yearly Premium: $_____________________

Cash Surrender/Loan Value______________

Health Insurance:

You

_____ Medical

_____ Hospitalization

_____ Dental

_____ Orthodontic

_____ Visual

_____ Nursing home

Through employment?_______

Provider _________________

Cost for Employee only coverage _________________

Your Spouse

_____ Medical

_____ Hospitalization

_____ Dental

_____ Orthodontic

_____ Visual

_____ Nursing home

Through employment?_______

Provider _________________

Cost to add spouse to coverage___________________

Your Children

_____ Medical

_____ Hospitalization

_____ Dental

_____ Orthodontic

_____ Visual

_____ Nursing home

Through employment?______

Provider _________________

Cost to add children to coverage___________________

If any of the above policies are not obtained through employment or a union, from whom do you purchase the policies?____________________________________________________________________

Do you have insurance available through your work? ______________Does your spouse?____________

Other employee benefits:

Stock options, savings plan, profit sharing, commission, expense accounts, etc. you or your spouse

have through employment:___________________________________________________________

_________________________________________________________________________________

Pension and Retirement Plans through Employment:

YOU

Type of Plan:____________________________

Plan Administrator ________________________

Model Plan language available?______________

Amount or Percentage of Vesting:___________

Estimated present cash value:_______________

YOUR SPOUSE

Type of Plan:____________________________

Plan Administrator ________________________

Model Plan language available?______________

Amount or Percentage of Vesting:___________

Estimated present cash value:_______________

Defined Contribution Retirement Plans

401(k), 403(b), 401(a), Thrift Savings Plan, Deferred Compensation, etc.

YOU

Type of Plan: ____________________________

Amount or Percentage of Vesting:___________ Date of full vesting:_______________________

Employee contribution per pay period:_______

Estimated present cash value:_______________

YOUR SPOUSE

Type of Plan:____________________________

Amount or Percentage of Vesting:___________ Date of full vesting:_______________________

Employee contribution per pay period:_______

Estimated present cash value:_______________

Type of Plan: ____________________________

Amount or Percentage of Vesting:___________ Date of full vesting:_______________________

Employee contribution per pay period:_______

Estimated present cash value:_______________

Type of Plan:____________________________

Amount or Percentage of Vesting:___________ Date of full vesting:_______________________

Employee contribution per pay period:_______

Estimated present cash value:_______________

Type of Plan: ____________________________

Amount or Percentage of Vesting:___________ Date of full vesting:_______________________

Employee contribution per pay period:_______

Estimated present cash value:_______________

Type of Plan:____________________________

Amount or Percentage of Vesting:___________ Date of full vesting:_______________________

Employee contribution per pay period:_______

Estimated present cash value:_______________

Individual Retirement Accounts or Plans

|Name on account |Account Number |Company |Current Value |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Non-marital Claims:

Please identify any potential non-marital claims that you or your spouse may have (Inheritance, gifts from third parties, personal injury awards, property owned prior to marriage).

|Asset |When acquired |How acquired |Who’s NM claim |Estimated value |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Debts:

Please provide the following information regarding any debts owed by yourself, your spouse, or jointly (attach a Credit Report if possible)

|Creditor |Purpose |Incurred by whom |Balance and Monthly Pymt |Names on Account |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Other Information:

State the date, purpose and individuals involved in any counseling (marriage, individual, anger, chemical dependency, etc.) for you and/or your spouse. _______________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you feel that there is any chance to save this marriage?______________________________________ ____________________________________________________________________________________

Summarize the situation of your spouse's conduct that you feel may have caused the breakdown of your marriage relationship. __________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What would be your spouse's primary complaints about you?___________________________________ ________________________________________________________________________________________________________________________________________________________________________

Do you expect a contest over who should have custody of the children? ___________________________

Explain______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you or your spouse currently involved in a lawsuit? _________ Attorney’s name_________________

Explain______________________________________________________________________________

____________________________________________________________________________________

Is domestic abuse (physical) an issue between you and your spouse?_____________________________

Is there an Order for Protection?____________ County_______________________________________

What was the date of the last incident of domestic abuse ________________Briefly describe the incident ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The information that I have provided in this questionnaire is truthful and a complete account to the best of my knowledge.

_______________________ _____________________________________

Date Client’s signature

Necessary Monthly Expenses:

|Rent | |

|Mortgage Payment | |

|2nd Mortgage/Home Equity/or CD Payment | |

|Homeowner’s Insurance | |

|Real Estate Taxes | |

|Maintenance and Repairs | |

|Yard Service/Gardening | |

|Association Fee | |

|Electricity | |

|Heat | |

|Sewer/Water | |

|Regular Phone Service | |

|Long Distance | |

|Cell/Pager | |

|Garbage | |

|Internet Service Provider, DSL | |

|Cable | |

|  | |

|  | |

|Food | |

|Restaurants | |

|Carryout | |

|Liquor | |

|Clothing/Shoes | |

|Laundry and Dry Cleaning | |

|  | |

|  | |

|Medical (not covered by insurance) | |

|Dental (not covered by insurance) | |

|Orthodontist | |

|Eyeglasses | |

|Medicine/Drugs | |

| | |

|Therapy/Counseling | |

|  | |

| | |

| | |

| | |

|Car Payment/Replacement | |

|Car Insurance | |

|Gasoline | |

|Oil Changes | |

|Repairs/Maintenance | |

|Parking/Garage Rental | |

|License/Tabs/Driver’s License | |

|Bus/Public Transport | |

|  | |

|Disability Insurance | |

|Life Insurance | |

|Medical (if not payroll deducted) | |

|Accident/Personal Umbrella/Long term Care | |

|Insurance | |

|  | |

|Memberships/Clubs | |

|Newspapers/Books/Magazines | |

|Pet Expenses | |

|Vacations | |

|Entertainment | |

|Hobbies | |

|Donations/Worship | |

|Gifts | |

|Cosmetics/Toiletry | |

|Barber/Beautician | |

|Personal Allowances and Incidentals | |

|Child Care | |

|Babysitting | |

|Allowances | |

|Summer/Day Camp | |

|Lessons/Activities | |

|School Needs | |

|Diaper Service | |

|Toys/Books/Etc. | |

|Prior Child/Spousal Support | |

|Employment Costs | |

|Income Tax Deposits | |

|Debt Payments | |

|  | |

Client To Do list:

This list is for your benefit. Use it as a guide as you gather information. You can keep you legal costs down if you gather the information yourself. If you do not have access to necessary information, the Wright Law Office will formally request it from your spouse. As you gather the documents and provide them to the Wright Law Office, mark the appropriate box. If the requested information is not relevant to your file, mark N/A in the space.

|Document |You |Spouse |Document |You |Spouse |

|Paycheck stubs | | |Credit report | | |

|Pension/Retirement accounts | | |Credit card statements | | |

|Health Insurance | | |Other outstanding bills | | |

|Life Insurance Policies | | |Bank statements | | |

|Tax Returns (3 years) | | |Checkbook registers | | |

|Deeds to Real Estate | | |Investment information | | |

|Mortgage documents | | |Automobile Titles | | |

|Tax assessment on Real estate | | | | | |

|Proof of Non-marital asset | | | | | |

Phone Calls to Make; Additional information to gather; Priorities ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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