DIVORCE/SEPARATION INTAKE FORM

INFORMATION FOR YOUR SPOUSE

www.DivorceByMail.com
SPOUSE'S FULL NAME:

Prefix First Name Middle Name Last Name Suffix
SPOUSE'S DATE OF BIRTH:

Month Day Year
SPOUSE'S GENDER:

Male Female
SPOUSE'S E-MAIL:
example@example.com
DO YOU KNOW YOUR SPOUSE'S HOME ADDRESS?

Yes No

SPOUSE'S HOME ADDRESS (If you do not know your spouse's home address, please list their last known address):

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

IF YOUR SPOUSE LIVES IN VIRGINIA, HOW MANY YEARS/MONTHS?
SPOUSE'S CELL PHONE NUMBER:

Area Code Phone Number
SPOUSE'S E-MAIL:
example@example.com
IS YOUR SPOUSE IN THE MILITARY?

Yes No
IF YOUR SPOUSE IS IN THE MILITARY, WHICH BRANCH OF SERVICE AND HOW LONG?
IS YOUR SPOUSE INCARCERATED IN JAIL OR IN PRISON?

Yes No
IF YOUR SPOUSE IS INCARCERATED, WHERE AND WHAT IS THE INMATE NUMBER?

INFORMATION FOR CHILDREN

(YOU MAY SKIP THIS SECTION IF THERE ARE NO CHILDREN INVOLVED BY SCROLLING TO THE BOTTOMS AND SKIPPING NEXT)
IF THERE WERE CHILDREN BORN OR ADOPTED OF THIS MARRIAGE, WERE THE CHILDREN CONCEIVED, FATHERED OR ADOPTED IN VIRGINIA?

Yes No
DO YOU OR YOUR SPOUSE HAVE CHILDREN FROM A PREVIOUS RELATIONSHIP?

Yes No
IF YOU OR YOUR SPOUSE HAVE CHILDREN FROM A PREVIOUS RELATIONSHIP, DID YOU ARE YOUR SPOUSE LEGALLY ADOPT THE OTHER SPOUSE'S CHILDREN?

Yes No
LIST THE INFORMATION FOR ALL CHILDREN BORN OF THE MARRIAGE (DO NOT LIST A CHILD IF ONLY ONE SPOUSE IS THE PARENT AND THE OTHER SPOUSE DID NOT ADOPT THE CHILD).
WHO WILL HAVE PHYSICAL CUSTODY OF THE CHILDREN AND WHAT WILL BE THE VISITATION ARRANGEMENTS FOR THE CHILDREN? FOR EXAMPLE, WHO WILL HAVE RESIDENTIAL/PHYSICAL CUSTODY - REASONABLE VISITATION? NOTE - IF YOU WANT CUSTODY ORDERED IN THE FINAL DIVORCE DECREE, A SEPARATION AGREEMENT WILL BE REQUIRED (WE CAN PREPARE ONE FOR YOU).
WHO WILL HAVE LEGAL CUSTODY, MEANING WHO WILL HAVE A SAY IN DECISIONS CONCERNING THE HEALTH, SAFETY, WELFARE, EDUCATION, ETC. OF THE CHILDREN? NOTE - IF YOU WANT CUSTODY ORDERED IN THE FINAL DIVORCE DECREE, A SEPARATION AGREEMENT WILL BE REQUIRED (WE CAN PREPARE ONE FOR YOU).
WHAT ARE THE ARRANGEMENTS FOR CHILD SUPPORT? HOW MUCH WILL BE PAID TO WHICH SPOUSE? BEGINNING DATE?
WHO WILL PROVIDE HEALTH INSURANCE COVERAGE FOR THE CHILDREN? PLEASE PROVIDE NAME OF THE INSURED, NAME OF INSURANCE COMPANY AND POLICY NUMBER.
WHO WILL PAY FOR UN-REIMBURSED/UNCOVERED MEDICAL EXPENSES FOR THE CHILDREN? FOR EXAMPLE - 50/50 SPLIT?
WHAT WILL BE THE ARRANGEMENTS FOR LIFE INSURANCE, IF ANY? FOR EXAMPLE, WILL EACH PARTY HAVE LIFE INSURANCE POLICIES WITH THE CHILDREN AS THE BENEFICIARIES? IF SO, HOW MUCH?
WHAT WILL BE THE ARRANGEMENTS, IF ANY, FOR THE PAYMENT OF COLLEGE TUITION AND EXPENSES FOR THE CHILDREN BORN OR ADOPTED OF THE MARRIAGE?
WHO WILL CLAIM THE CHILDREN ON THEIR CURRENT AND FUTURE TAX RETURN?

You will claim them Your spouse will claim them

VS4 FORM INFORMATION

THIS INFORMATION MUST BE PROVIDED TO THE COURT. PLEASE COMPLETE IN ITS ENTIRETY.
YOUR FULL NAME

First Name Middle Name Last Name Suffix
YOUR SOCIAL SECURITY NUMBER
YOUR PLACE OF BIRTH
YOUR PLACE OF BIRTH
YOUR DATE OF BIRTH

Month Day Year
Date
YOUR RACE
YOUR GENDER
NUMBER OF THIS MARRIAGE (first, second, etc.)
ELEMENTARY OR SECONDARY EDUCATION (0-12th GRADE) specify only highest grade completed)
COLLEGE EDUCATION (1-4 OR 5+) specify only highest grade completed)

YOUR USUAL RESIDENCE

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

SPOUSE'S FULL NAME

First Name Middle Name Last Name Suffix
SPOUSE'S SOCIAL SECURITY NUMBER
SPOUSE'S PLACE OF BIRTH
SPOUSE'S DATE OF BIRTH

Month Day Year
Date
SPOUSE'S RACE
SPOUSE'S GENDER
NUMBER OF THIS MARRIAGE (first, second, etc.)
ELEMENTARY OR SECONDARY EDUCATION (0-12th GRADE) specify only highest grade completed)
COLLEGE EDUCATION (1-4 OR 5+) specify only highest grade completed)

SPOUSE'S USUAL RESIDENCE

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PLACE OF MARRIAGE
DATE OF MARRIAGE

Month Day Year
Date
DATE OF SEPARATION

Month Day Year
Date
NUMBER OF CHILDREN UNDER THE AGE OF 18 IN THIS FAMILY

WITNESS INFORMATION

YOUR WITNESS MUST BE OVER THE AGE OF 18 AND MUST BE ABLE TO TESTIFY THAT YOU HAVE BEEN LIVING SEPARATE AND APART FOR THE STATUTORY PERIOD (1 YEAR OR 6 MONTHS SEPARATION)
NAME OF YOUR WITNESS

First Name Middle Name Last Name Suffix

ADDRESS OF YOUR WITNESS

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

HOW DOES THE WITNESS KNOW YOU AND HOW LONG HAVE THEY KNOW YOU? SINCE WHAT YEAR HAVE THEY KNOW YOU?
DOES THE WITNESS KNOW YOUR SPOUSE?

Yes No
IF THE WITNESS DOES KNOW YOUR SPOUSE, DID HE OR SHE ATTEND YOUR WEDDING?

Yes No
DOES THE WITNESS HAVE PERSONAL KNOWLEDGE ABOUT THE SEPARATION AND CAN THE WITNESS TESTIFY AS TO THE DATE OF SEPARATION?

Yes No

Liberty Law Group will represent you in: *

An Uncontested Divorce Separation Agreement Both an Uncontested Divorce and Separation Agreement
Your Name

First Name Last Name
Today's Date

Month Day Year
Date
Signature

Clear

UNCONTESTED DIVORCE FEE AGREEMENT TOTAL FEE: $1250.00 Attorney Fee + $90.00 for the Court Filing Fee (If Spouse will agree and sign Waiver) = TOTAL: $1340.00. THE AVERAGE UNCONTESTED “NO-FAULT” DIVORCE IS USUALLY FINALIZED WITHIN 60-90 days (sometimes sooner), PROVIDED YOUR SPOUSE PROMPTLY SIGNS AND RETURNS THE WAIVER AND ACCEPTANCE OF SERVICE DOCUMENTS. IF YOU REQUIRE RUSH SERVICE, THERE IS AN ADDITIONAL $350.00 RUSH FEE. RUSH CASES ARE GENERALLY FINALIZED WITHIN 2 TO 3 WEEKS, SOMETIMES SOONER, PROVIDED YOUR SPOUSE PROMPTLY SIGNS AND RETURNS THE WAIVER AND ACCEPTANCE OF SERVICE FORM. THE FOLLOWING IS A LIST OF ADDITIONAL CHARGES, WHICH USUALLY ARE NOT REQUIRED IN THE AVERAGE UNCONTESTED “NO-FAULT” DIVORCE CASE WHERE SPOUSE WILL COOPERATE AND SIGN WAIVER. If the following items are required in your case, you will be responsible for payment of the fees. Office Consultation (At the request of the client, attorney will set a face-to-face office consultation) ($95.00) Private Process Server/Sheriff’s Fee (If your spouse does not sign and return the Proof of Service and Waiver) (Varies) Attorney Fee (if spouse will not sign waiver and will require service by Sheriff/Private Process Server ($495.00) QDRO or Military Division Order for Retirement Division ($2500.00) Quit Claim Deed/Marital Deed ($750.00) Additional Notices Required in Final Divorce Decree (when Child or Spousal Support Ordered) ($250.00) Guardian Ad Litem (If spouse is incarcerated or in military and will not sign waiver) (varies-approx. $350.00) Order of Publication (If spouse is out-of-state and won’t sign Acceptance of Service/Waiver OR spouse’s whereabouts unknown) ($250.00 payable to “Inside Business” newspaper and add $245.00 payable to Liberty Law Group for the attorney fee = $495.00 total for Order of Publication) Restoration of Maiden Name ($100.00 for the attorney fee plus $22.00 for the filing fee,) Amended Complaint ($350.00) Motion to Withdraw/Non-Suit ($350.00) Additional Court Appearance (If a court hearing is required and client cancels or does not show at the scheduled hearing) ($350.00) NOTE: YOU MUST HAVE A WITNESS FOR EVERY DIVORCE CASE AND ANY BALANCE DUE MUST BE PAID IN FULL PRIOR TO THE ENTRY OF THE FINAL DIVORCE DECREE. _______________________________________________________________ SEPARATION AGREEMENT FEE AGREEMENT Standard Separation Agreement ($950.00). There will be an additional $150.00 fee for any changes requested to the separation agreement after the final draft has been prepared. Changes required to be made resulting from negotiations with the attorney of client’s spouse or for any reason other than an omission, discrepancy or error in typing the original Agreement by Liberty Law Group will also result in an additional fee. Short Form Separation Agreement ($499.00). Client has no children with his/her spouse, and is not seeking spousal support, property or division of debts. Amendment or Modification to a Separation Agreement ($499.00). Client has an existing signed separation agreement, but needs to make changes. _______________________________________________________________ If any of the above costs/fees increase or must be incurred more than anticipated (i.e. service of process), such cost shall be the responsibility of the client. Liberty Law Group is NOT obligated to provide you with any legal services until the payment terms set forth above have been met. You have the right to terminate our services, in writing at any time and we can terminate our services upon written notice to you if you fail to pay your monthly billing statement or if we determine that your case is more complex that anticipated or that it would be unethical or impractical to continue our representation. However, Liberty Law Group shall deduct from any retainer or monies on deposit with our firm, any fees owed for work done up until the attorney has officially withdrawn or completed working on your case. You are receiving the flat fee as stated above; however, if this were to occur, or if your case were to become contested, your billing shall convert from the flat fee listed above to hourly billing (retroactive to the date of retention). Compensation for attorney's fees will be as follows: Attorney fee is $300.00 per hour; paralegal fee $95.00 per hour. There is a minimum billing of .10 hours (6 minutes) for any telephone calls to or from you or anyone involved in your case, and a minimum billing of .10 (6 minutes) for any written correspondence we send, whether by email, fax, US Mail, or any other method. There is a billing of one dollar per page for all faxes sent to or from this office concerning your case and twenty-five cents per page for all copies made. If client decides to discontinue the case because of reconciliation of the parties, or for any other reason, client is still responsible for the full attorney fee listed in this fee agreement and shall also be responsible for the fee for the Non-Suit or Motion to Dismiss/Withdraw. If any long-distance phone charges, overnight delivery, courier or certified mail expenses are necessary, they shall be charged to the client’s account. Deposit is non-refundable. There is a $35.00 charge for all checks returned unpaid and client agrees to be responsible for any collections fees and/or attorney’s fees that may be incurred resulting from your failure to pay for services rendered in accordance with this agreement. If paying by debit or credit card, there is a 3% merchant fee or a minimum of $4.95 merchant fee for all payments processed. If a billing statement is not paid in full when due, interest will be charged on the principal balance (fees, costs, and disbursements) shown on the statement. Interest will be calculated by multiplying the unpaid balance by the periodic rate of .833% per month (TEN PERCENT [10%] ANNUAL PERCENTAGE RATE). The unpaid balance will bear interest until paid. Your signature below acknowledges that the above terms and conditions accurately reflect your understanding of our attorney-client relationship. Liberty Law Group By: /s/ Timolyn Whitney Tillman Timolyn Whitney Tillman, Senior Managing Attorney
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DIVORCE/SEPARATION INTAKE FORM

INFORMATION FOR YOU

INFORMATION FOR YOUR SPOUSE

CASE INFORMATION

INFORMATION FOR CHILDREN

ASSETS AND LIABILITIES

VS4 FORM INFORMATION

WITNESS INFORMATION