DIVORCE/SEPARATION INTAKE FORM
COMPLETE THIS FORM FOR DIVORCE AND/OR SEPARATION AGREEMENT www.libertylawgroupva.com
TODAY'S DATE:
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Month
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Day
Year
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WHERE DID YOU SEE OUR AD OR HOW DID YOU HEAR ABOUT US?
SERVICES DESIRED (Check all that apply):
Uncontested "No-Fault" Divorce
Separation Agreement
Contested Divorce
Other
INFORMATION FOR YOU
www.DivorceByMail.com
YOUR FULL NAME:
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
YOUR DATE OF BIRTH:
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Month
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Day
Year
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YOUR GENDER:
Male
Female
YOUR E-MAIL:
example@example.com
MAY WE COMMUNICATE WITH YOU VIA E-MAIL?
Yes
No
ARE YOU IN THE MILITARY?
Yes
No
IF YOU ARE IN THE MILITARY, WHICH BRANCH OF SERVICE?
YOUR HOME ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
IF YOU LIVE IN VIRGINIA, HOW MANY YEARS/MONTHS HAVE YOU LIVED IN VA?
YOUR MAILING ADDRESS (If different than your home address):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
YOUR CELL PHONE NUMBER:
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Area Code
Phone Number
YOUR HOME PHONE NUMBER:
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Area Code
Phone Number
YOUR WORK PHONE NUMBER:
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Area Code
Phone Number
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INFORMATION FOR YOUR SPOUSE
www.DivorceByMail.com
SPOUSE'S FULL NAME:
Prefix
First Name
Middle Name
Last Name
Suffix
SPOUSE'S DATE OF BIRTH:
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Month
-
Day
Year
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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
IF YOUR SPOUSE LIVES IN VIRGINIA, HOW MANY YEARS/MONTHS?
SPOUSE'S CELL PHONE NUMBER:
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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?
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CASE INFORMATION
DATE OF MARRIAGE:
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Month
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Day
Year
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WHERE WERE YOU MARRIED (CITY AND STATE)?
ARE YOU PRESENTLY LIVING SEPARATE AND APART FROM YOUR SPOUSE?
Yes
No
Separated - but living under the same roof
Never Lived together
IF SEPARATED, WHAT IS THE DATE OF SEPARATION? IF YOU NEVER LIVED TOGETHER, WHAT IS THE DATE THAT YOU FORMED THE INTENT TO SEPARATE PERMANENTLY?
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Month
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Day
Year
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WHERE DID YOU LAST LIVE TOGETHER AS HUSBAND AND WIFE (CITY AND STATE)?
DO YOU HAVE A SIGNED SEPARATION AGREEMENT?
Yes
No
IF YOU DO NOT HAVE A SEPARATION AGREEMENT, DO YOU WANT OUR FIRM TO PREPARE ONE FOR YOU?
Yes
No
IF YOU HAVE A SIGNED SEPARATION AGREEMENT, PLEASE UPLOAD OR FAX OR E-MAIL IT TO OUR OFFICE:
Upload a File
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DO YOU HAVE A COPY OF YOUR MARRIAGE CERTIFICATE?
Yes
No
IF YOU HAVE A COPY OF YOUR MARRIAGE CERTIFICATE, PLEASE UPLOAD OR FAX OR E-MAIL IT TO OUR OFFICE:
Upload a File
Cancel
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WHO LEFT THE MARITAL RESIDENCE WHEN YOU SEPARATED?
I left the marital residence
My spouse left the marital residence
Both spouses left the marital residence
Other
UP UNTIL THE TIME OF SEPARATION, DID YOU AND YOUR SPOUSE HAVE A HOME OR APARTMENT TOGETHER IN VIRGINIA?
Yes
No
HOW WILL YOUR SPOUSE NEED TO BE SERVED WITH THE SUMMONS AND COMPLAINT FOR DIVORCE ONCE IT IS FILED?
Spouse will cooperate and sign a Waiver and Acceptance of Service
Spouse will need to be served by the Sheriff or Private Process Server
Spouse's whereabouts are unknown and will need to be served by Order of Publication
WHAT ARE THE ARRANGEMENTS FOR SPOUSAL SUPPORT?
BOTH SPOUSES WAIVE SPOUSAL SUPPORT
I AM SEEKING SPOUSAL SUPPORT BUT MY SPOUSE DOES NOT AGREE TO PAY
MY SPOUSE IS SEEKING SPOUSAL SUPPORT BUT I DO NOT AGREE TO PAY
MY SPOUSE HAS AGREED TO PAY ME SPOUSAL SUPPORT
I HAVE AGREED TO PAY MY SPOUSE SPOUSAL SUPPORT
Other
IF THERE IS AN AGREEMENT TO PAY SPOUSAL SUPPORT, PLEASE PROVIDE THE INFORMATION:
WHAT ARE THE ARRANGEMENTS FOR HEALTH INSURANCE COVERAGE FOR EACH SPOUSE?
EACH SPOUSE WILL PROVIDE HIS OR HER OWN COVERAGE
I WILL KEEP MY SPOUSE COVERED UNTIL ENTRY OF THE FINAL DIVORCE DECREE
MY SPOUSE WILL KEEP ME COVERED UNTIL ENTRY OF THE FINAL DIVORCE DECREE
Other
WHAT WILL BE THE ARRANGEMENTS, IF ANY, FOR THE PAYMENT OF UN-REIMBURSED/UNCOVERED MEDICAL EXPENSES FOR EITHER SPOUSE? FOR EXAMPLE, EACH WILL PAY THEIR OWN?
DO YOU OR YOUR SPOUSE WANT TO BE RESTORED TO YOUR FORMER OR MAIDEN NAME UPON ENTRY OF THE FINAL DIVORCE DECREE?
Yes
No
IF EITHER SPOUSE WANTS TO BE RESTORED TO A FORMER OR MAIDEN NAME, LIST ALL FORMER NAMES USED AND DATES THOSE NAMES WERE USED:
WERE THERE ANY CHILDREN BORN OR ADOPTED OF THIS MARRIAGE?
Yes
No
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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
Other
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ASSETS AND LIABILITIES
www.DivorceByMail.com
DO YOU AND YOUR SPOUSE HAVE ANY OF THE FOLLOWING ASSETS?
No assets
Bank Accounts, CDs Money Market Funds
Securities, Stocks, Bonds
Life Insurance with case value
Personal effects, furniture
Retirement plans, pension, profit sharing, Keoghs, IRAs
Automobiles
Military retirement
Real estate
ARE YOU SEEKING DIVISION OF ANY OF THE ASSETS LISTED ABOVE OR ANY OTHER ASSETS?
Yes
No
Assets have already been divided
IF YOU ARE SEEKING DIVISION OF ASSETS, LIST DETAILS HERE:
IF YOU ARE SEEKING A PORTION OF YOUR SPOUSE'S MILITARY RETIREMENT, OR ANY OTHER PENSIONS OR RETIREMENT PLANS, LIST DETAILS HERE:
WILL JOINT TAX RETURNS BE FILED FOR THE CURRENT TAX YEAR?
Yes
No
ARE THERE ANY DEBTS OR LIABILITIES TO BE DIVIDED?
Yes
No
IF YOU ARE SEEKING DIVISION OF DEBTS OR LIABILITIES, LIST DETAILS HERE:
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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
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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
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
PLACE OF MARRIAGE
DATE OF MARRIAGE
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Month
-
Day
Year
Date
DATE OF SEPARATION
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Month
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Day
Year
Date
NUMBER OF CHILDREN UNDER THE AGE OF 18 IN THIS FAMILY
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Liberty Law Group will represent you in:
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An Uncontested Divorce
Separation Agreement
Both an Uncontested Divorce and Separation Agreement
Other
Your Name
First Name
Last Name
Today's Date
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Year
Date
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