Dissoulution/Separation Intake Sheet

DISSOLUTION/SEPARATION
(Print out this form and fill in the confidential questions as best you can)

Full Name: _______________________________________________________Date:_________________

Mailing Address:________________________________________________________________________

Birthdate: ________Age ______Vehicles:_________________________Debts:_____________________

Soc. Security No: __________Telephone (H) _______________Work:____________________

Public Assistance: __________________Job Description: __________________________________

Address:_____________________________________________ Phone:_____________________________

FICA: $_________________ Pension $_________________Union Dues $__________________

Full Name: _______________________________________________________Date:_________________

Mailing Address:________________________________________________________________________

Birthdate: ________Age ______Vehicles:_________________________Debts:_____________________

Soc. Security No: __________Telephone (H) _______________Work:____________________

Public Assistance: __________________Job Description: __________________________________

Address:_____________________________________________ Phone:_____________________________

FICA: $_________________ Pension $_________________Union Dues $__________________

Marriage Date ___________ City, County & State of Marriage: ______________________________________

Separation Date: ___________Who Referred You to Us____________________________________________

Have you lived in Minnesota for the last six months? Yes___ No___ How Long:_____

Describe any prior separation from your spouse:____________________________________________________

Have you or your spouse ever filed for divorce or separation before? Yes_ No_ If yes, when_________

County: ______________State____________, and date dismissed:______________________

Does wife (you or spouse) desire a name change? Yes___ N___
New Name Desired_______________________

If I need to reach you quickly, individual most likely to get in touch with your: Name__________________________

Address:________________________________________________Phone:_____________________________

Explain any current pregnancy: _____________________________________Due Date:_____________

Which parent(s) should be awarded LEGAL CUSTODY, the right to recieve medical and educational information and sharing in the decision-making process which affects major issues in a child's life, such as religious upbringing, and why (usually its both parents)?______________________________________________________________________

_________________________________________________________________________________________

Which parent(s) whould be awarded PHYSICAL CUSTODY, the right of the parent to raise the child on a daily basis, and why? _____________________________________________________________________________

_________________________________________________________________________________________

What type of visitation schedule would you like to see including: __ Alternating weekends, __ Summer visitation
for___ weeks/months (circle one/none), ___ Alternating holidays, and __ other, describe:

_________________________________________________________________________________________

Describe spouse's current living arrangements, including any significant other, in detail:_____________________

_________________________________________________________________________________________

Describe your current living arrangements, including any significant other, in detail:_______________________

______________________________________________________________________________________

List any pending lawsuit & circumstances:__________________________________________________________

Describe any bankruptcy either of you have or will file:________________________________________

Explain whether either of you have been investigated by Social Services or have had a DUI or other traffic violation involving the children:_________________________________________________________________________

Describe any child support or maintenance (alimony) you or spouse receive from a previous relationship:

_____________________________________________________________________________________

Describe any child support or maintenance (alimony) you or spouse are paying to a third party:

_________________________________________________________________________________________
Please attach a copy of any previous Court Order which awards child support or maintenance.

Name of any child's counselor and the nature of any councelling;_________________________________________

_________________________________________________________________________________________

List any physical/emotional disabilities of any child:___________________________________________________

Where did down payment come from? _____________________________________________________

Describe the nature and cost of any major improvement since purchase :_____________________________
___________________________________________________________________________________

Describe any life insurance policies for the children: __________Carrier: _________Value$____________

Pension/profit Sharing Plan	Husband	Wife
Name of plan and type of plan, e.g. IRA, 401K, employer pension plan	.	.
Name of administrator	.	.
Present cash value	.	.
Vested or nonvested	.	.

If either have borrowed against the cash value of any of the above policies, please explain date_____________

the purpose ___________________________________and amount borrowed $_____________________

Describe any claim for spousal maintenance (alimony)___________________________________________

Your educational background:__________________________College ____________________________

Spouse's educational background: _________________________College: __________________________

Your previous work history:______________________________________________________________

Spouse's previous work history: ___________________________________________________________

Your contribution to spouse's business career or education: _______________________________________

Spouse's contribution to your business career or education: _______________________________________

How many exemptions do you claim for tax withholding purposes? ________________________

Other income (Public Assistance such as AFDC/GA/MnPHP, S.S.I. or Disability, Workers Compensation, Unemployment, Interest/Dividend):_______________Amounts: $________per month/week/year (circle one).

Indicate which of you has any of the following through employer:___Health Insurance___Dental Insurance

Monthly Expenses are important aspect of your case. They may affect child support, maintenance, and property division issues. List all of your monthly expenses in detail. If you are paying an expense on behalf of your spouse, list it separately in column for "SPOUSE"; likewise for any expense you pay for child. Do not fill in the fourth column marked "ATTY", as this is reserved for office use. If you are having trouble figuring out how much you typically spend on an item, use your check book for assistance, or make your best effort to estimate the amount.

Item	You	Spouse	Kid(s)	ATTY
Rent/Mortgage/CFD	.	.	.	.
Insurance/Taxes (____/yr)	.	.	.	.
Utilities (elec.,gas,cable,TV,phone)	.	.	.	.
Heat (elec., gas, wood)	.	.	.	.
Food (groceries, eating out)	.	.	.	.
Clothing (include shoes, laundry, etc.	.	.	.	.
Medical and Dental (ins., drugs, eyes)	.	.	.	.
Transportation (car, fuel, oil, ins., etc.)	.	.	.	.
Life Insurance	.	.	.	.
Entertainment, Recreation	.	.	.	.
Social/Church Obligations	.	.	.	.
Misc. cosmetic, liquor, cig., pets, gifts	.	.	.	.
Babysitting and Child Care	.	.	.	.
Home Maintenance	.	.	.	.
Child School Needs	.	.	.	.
Monthly visa/mastercard/discover, etc.	.	.	.	.
Monthly Penney/Sears/Dayton, etc.	.	.	.	.
Monthly gas credit cards, etc.	.	.	.	.
Monthly Misc. Other	.	.	.
Total

Personal Property includes all vehicles, RV's, motorcycles, snowmobiles, boats, etc: Have you and spouse already divided personal property, including household goods & furnishings?_____________________________________

Assets	Current Value	$ Debt	$ Equity	Title	How Acquired	$ Value at Acquist'n	Date Acquired
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Non-marital Property was acquired solely by a spouse before the marriage, or inherited during the marriage. Indicate such items, how they were acquired, and their present values.

Debt Holder Name & Address	Current Balance	Name on Debt	Payment Amount	Purpose of Loan/Security	Original Amount	Origination Date
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Do you understand the attorney you hire to represent you looks to you for payment of legal fees, and not to
your spouse? Yes___ No___

Copies of all earning information such as:
* Fed. & State Tax Returns for the past three years, including W-2's and all forms
* Pay stubs from your employer
* Pay stubs from your spouse's employer

Copies of all Court Orders such as:
* Child Support Orders
* Maintenance
* Order for Protection
* Harassment, Restraining Orders

Copies of all deeds of any real estate in which you and your spouse have an interest. (If you don't have a copy in your possession, you can order a copy from the Recorder's Office in the county where the property is located).

Copies of all the following:
* Life Insurance Policies
* Banking Records including checking and savings statements
* Stocks/Bonds/Mutual Funds/Safe deposit box/CD's/Treasury Notes/Etc
* Pension/Profit sharing plans
* Photograph of spouse
* Other_______________________________________________________________________________

Provide any information not covered by this questionnaire that you believe is important:

___________________________________________________________________________________

Real Estate Legal Description (attach copy of deeds, etc; also describe any well regardless of whether in use)	Home Stead	* Other
Present Fair Market Value	.	.
less all Mortgage Balances, etc.	.	.
Equals Net Value:	.	.
Date purchased	.	.
Purchase price	.	.
Insurance & Real Estate Taxes (yearly)	.	.
Monthly payment(s)	.	.
Down payment	.	.

Life Insurance	Husband	Wife
Name of company	.	.
Policy number	.	.
Value of policy	.	.
Cash value of policy	.	.
Beneficiary	.	.

Items	Gift	Premarital	Other	Value

Minor Children of Marriage	Birthdate	Age	Living With	*
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