Intake No Children

DATE:*

MonthDayYear
How did you hear about us? ( Please check/fill in so that we may thank your referral )*

Attorney (please put name below)Friend (please put name below)BillboardInternetOther

Client Info
Your Name:*

First NameLast Name
Maiden or other names (if applicable)*
How long have you lived in Florida?*
Date of Birth*

MonthDayYear
Do You Wish to Restore Your Maiden Name?*

YesNoUndecided
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Work Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
General Health
Last 4 of Your Social
What is Your Desired Outcome in This Matter?*
Date of Marriage

MonthDayYear
Place of Marriage

Client Info Closed

Your Employment
Current Employer?
Education
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
Job Type?
Monthly Gross?
Military Service? Please give details
Other:

Your Income Closed

Opposing Party
Opposing Party's Name Name:*

First NameLast Name
Currently Residing Together?*

YesNo
Spouse's Salary
Spouse's Date of Birth

MonthDayYear
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Education
Spouse's Employer
Nature of Job
Spouse's Phone

Area CodePhone Number
Military Service? Please give details
Spouse's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Employer's Phone Number

Area CodePhone Number
Does Spouse Wish to Restore Maiden Name?*

YesNoUndecided
Spouse's Maiden Name (if applicable)
Spouse's General Health

Opposing Party Close

Modification?
Place of Divorce
Date of Divorce

MonthDayYear
Modification of Prior Order?

AlimonyOther
Type of Modification:

Close Modification

Debts
Account 1
Balance Account 1
Is any part of Account 1 non-maritial?
(incurred prior to marriage or after separation)
Account 2
Balance Account 2
Is any part of Account 2 non-maritial?
(incurred prior to marriage or after separation)
Account 3
Balance Account 3
Is any part of Account 3 non-maritial?
(incurred prior to marriage or after separation)
Account 4
Balance Account 4
Is any part of Account 4 non-maritial?
(incurred prior to marriage or after separation)
More: List Account Name, Balance and non-maritial portion if applicable

debts close

Property
Property 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Market Value of Residence
Mortgage
More than 1 Property

NoYes
Property 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Property 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Details of Market Value and Mortgages on Other Properties

Property Close

Assets
Do You Have Health Insurance?

YesNo
If You Have Children, Are They Covered with Health Insurance?

YesNo
Policy Holder for Health Insurance
Do You Have Dental Insurance?

YesNo
Policy Holder for Dental Insurance
Do You Have Life Insurance?

YesNo
Policy Holder, Type and Amount of Life fnsurance
Have You Received a Personal Injury or Worker's Comp Settlement During the Marriage, if yes, How much?
Has Your Spouse a Personal Injury or Worker's Comp Settlement During the Marriage, if yes, How much?
Auto: Who Owns?
Year, Make, Model, Condition
Cost-Value
Auto: Who Owns?
Year, Make, Model, Condition
Cost-Value
Auto: Who Owns?
Year, Make, Model, Condition
Cost-Value

Assets Close
Should be Empty: