Client Questionnaire
[pic]
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 ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- questionnaire about yourself
- employee questionnaire about themselves
- fun employee questionnaire about themselves
- sample survey questionnaire for students
- getting to know you questionnaire kids
- demographic questionnaire sample
- get to know your staff questionnaire pdf
- hud recertification questionnaire form
- new patient health questionnaire forms
- customer service questionnaire sample
- medical history questionnaire pdf
- fun questionnaire for couples