DIVORCE--BASIC INFORMATION (INITIAL INTERVIEW)

 

DATE:_________________

 

CLIENT:

FULL NAME: ___________________________________________________________

RESIDENCE ADDRESS:__________________________________________________

          CITY:  ____COUNTY:         STATE:_____________
          HOME PHONE:                  OFHCE PHONE:________________

MAILING ADDRESS (IF DIFFERENT):______________________________________

          CITY: _____________________COUNTY:         STATE:___________

BIRTHDATE:__________________PLACE OF BIRTH:_________________________

EMPLOYER: ____________________________________________________________

POSITION: _____________________________________________________________

MONTHLY TAKE-HOME PAY:____________________________________________

SOCIAL SECURITY NO.__________________________________________________

DRIVER’S LICENSE NUMBER AND STATE OF ISSUANCE:

          _______________________________________________________________________

 

SPOUSE:

FULL NAME: ___________________________________________________________

RESIDENCE ADDRESS:__________________________________________________

          CITY:  ____COUNTY:         STATE:_____________
          HOME PHONE:                  OFHCE PHONE:________________

BIRTHDATE:__________________PLACE OF BIRTH:_________________________

EMPLOYER: ____________________________________________________________

POSITION: _____________________________________________________________

MONTHLY TAKE-HOME PAY:____________________________________________

WIFE PREGNANT?_____________WIFE’S MAIDEN NAME:___________________

DOES WIFE WISH TO HAVE HER MAIDEN NAME RESTORED?_______________

SOCIAL SECURITY NO.__________________________________________________

DRIVER’S LICENSE NUMBER AND STATE OF ISSUANCE:

          _______________________________________________________________________

 

RESIDENCE:

HAVE YOU LIVED IN TEXAS FOR THE PAST 6 MONTHS?_______________ HAVE YOU LIVED IN THIS COUNTY FOR THE PAST 90 DAYS?_______________

HAS YOUR SPOUSE LIVED IN TEXAS FOR THE PAST 6 MONTHS?_________ HAS YOUR SPOUSE LIVED IN THIS COUNTY FOR THE PAST 90 DAYS?______

 

MARRIAGE AND SEPARATION:

DATE OF MARRIAGE:___________________________________________________

PLACE OF MARRIAGE:__________________________________________________

DATE OF LAST SEPARATION:____________________________________________

 

ATTORNEYS:

IF YOU HAVE CONSULTED WITH ANOTHER ATTORNEY ON THIS MATTER, GIVE HIS NAME:________________________________________________________

IF YOUR SPOUSE HAS, THEN GIVE THE ATTORNEY’S NAME:

          _______________________________________________________________________

 

CHILDREN:

 

FULL NAME             GENDER        BIRTHDATE             BIRTHPLACE  LIVES WITH

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

          IF THE CHILDREN HAVE EVER BEEN THE SUBJECT OF OR INVOLVED IN A COURT ROOM ACTION BEFORE THEN STATE WHEN, WHERE, WHAT IT CONCERNED, WHO WAS INVOLVED AND ANY OTHER RELEVANT DETAILS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

IF ANY OF THE CHILDREN HAVE PHYSICAL OR MENTAL DISABILITIES TO THE POINT THAT HE OR SHE REQUiRES SPECIAL CARE, GIVE THE CHILD’S NAME, DiSABILITY, AND CURRENT ARRANGEMENTS FOR CARE WHICH PARENT DESIRE CUSTODY OF THE CHILDREN?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

 

IS ANY PROPERTY OWNED BY THE CHILDREN?___________________________

 

IF SO, DESIGNATE WHAT AND WHERE IT IS LOCATED AND WHAT INTEREST THE CHILD HAS IN IT:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

ARE ANY OF THE CHILDREN STEP CHILDREN?____________________________ IF SO, THEN TO WHOM? _______________________________________________________

______________________________________________________________________________

 

ARE ANY OF THE CHILDREN ADOPTED OR IS AN ADOPTION PENDING?

______________________________________________________________________________

 

IF SO, GIVE RELEVANT DETAILS: ________________________________________

______________________________________________________________________________

 

PROPERTY SKETCH:

 

ARE YOU RENTING OR BUYING YOUR HOME? ____________________________

 

IF BUYING:

ESTIMATE IT’S VALUE: ___________________________________________

ESTIMATE YOUR MORTGAGE LOAN BALANCE:_____________________

ESTIMATE VALUE OF CASH ASSETS (CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT ALSO):_____________________

DO YOU OWN STOCKS, BONDS, OR OTHER SECURITIES?_____________

IF SO, ESTIMATE THEIR PRESENT VALUE:__________________________

 

OTHER INVESTMENTS:

 

          ITEM                                                   ESTIMATED VALUE

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

          DESIGNATE THE LOCATION AND THE PERSON IN POSSESSION OF THE

ABOVE LISTED PROPERTY:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

          WHAT AMOUNT OF RETIREMENT, PROFIT-SHARING OR OTHER EMPLOYEE

BENEFITS WOULD YOU AND YOUR SPOUSE RECEIVE IF YOU LEFT EMPLOYMENT TODAY?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

LIST ANY INTEREST THAT YOU OR YOUR SPOUSE HAS IN ANY ABOVE MENTIONED BENEFITS WHETHER MATURED OR NOT:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

ESTIMATE THE TOTAL OF ALL YOUR DEBTS. EXCLUDING MORTGAGE LOAN BALANCE: _____________________________________________________________

 

COUNSELING:

 

IF YOU HAVE EVER SOUGHT MARRIAGE COUNSELING, GiVE DATES AND COUNSELORS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

WOULD COUNSELING HELP NOW?______________________________________ IS YOUR SPOUSE WILLING TO PARTICIPATE IN COUNSELING?_____________

 

IF YOU HAVE ANY URGENT PROBLEMS OR CONCERNS THAT NEED TO BE ADDRESSED IMMEDIATELY THEN PROVIDE THAT INFORMATION IN THE FOLLOWING SPACE ALONG WITH ANY ADDITIONAL COMMENTS:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

INVENTORY OF PROPERTY:

 

REAL PROPERTY:

 

(PLEASE ATTACH A COPY OF DEED AND OTHER LEGAL PAPERS CONCERNING EACH PIECE OF REAL ESTATE LISTED, IF POSSIBLE. IF ADDITIONAL SPACE IS REQUIRED, PLEASE USE THE BACK OF THIS SHEET).

 

ADDRESS: _____________________________________________________________

 

DESCRIPTION OF HOME OR OTHER STRUCTURE(S) LOCATED ON THE REAL

ESTATE: _____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

DATE OF PURCHASE:         ________________   PURCHASE PRICE: _________________ PRESENT MARKET VALUE:____________________________________________________

 

          METHOD OF ESTIMATING MARKET VALUE (SUCH AS PRICE PAID ON RECENT SALE OF COMPARABLE PROPERTY IN SAME LOCALE. OPINION OF REALTOR, FORMAL APPRAISAL OR PERSONAL GUESS BASED ON AVERAGE RATES OF APPRECIATION AND INFLATION): ___________________________________

______________________________________________________________________________

TOTAL CURRENT OUTSTANDING INDEBTEDNESS: $ ____________________________

MONTHLY PAYMENTS $_______________________________________________________

NUMBER OF YEARS REMAINING: ______________________________________________

HAS ANY OF THE PROPERTY BEEN DECLARED “HOMESTEAD”? __________________

IF SO, WHICH ONE? ___________________________________________________________

IS ANY OF THE PROPERTY INCOME-PRODUCING?_______________________________

IF SO, GIVE DETAILS: _________________________________________________________

______________________________________________________________________________

 

PERSONAL PROPERTY

 

VEHICLE(S):     (PLEASE FURNISH CERTIFICATE OF TITLE)

YEAR  _______________ MAKE___________________    MODEL______________________
YEAR  _______________ MAKE___________________    MODEL______________________
YEAR  _______________ MAKE___________________    MODEL______________________
YEAR  _______________ MAKE___________________    MODEL______________________
2 DOOR OR 4 DOOR: V8, 6,4; SPECIAL FEATURES

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

VIN NO._________________________       MILEAGE_________________________________

VIN NO._________________________       MILEAGE_________________________________

VIN NO._________________________       MILEAGE_________________________________

VIN NO._________________________       MILEAGE_________________________________

PURCHASE DATE:_____________________________________________________________

 

TOTAL CURRENT OUTSTANDING INDEBTEDNESS: $ ____________________________

 

MONTHLY PAYMENT $________________________________________________________

MONTHS REMAINING ON NOTE: _______________________________________________

IN WHOSE POSSESSION: ______________________________________________________

 

WHICH VEHICLE(S) DO YOU WANT?____________________________________________

 

RECORD OWNER:

 

RECORD OWNER:

 

RECORD OWNER:

 

RECORD OWNER:

 

FURNITURE

 

(THE DIVISION OF HOUSEHOLD FURNITURE AND APPLIANCES ISORDINARILY BETTER LEFT TO TILE HUSBAND AND WIFE AFTER BRIEFCONSULTATION WITH YOUR ATTORNEY. THIS IS BECAUSE MOST FURNITURE AND APPLIANCES DO NOT HAVE SIGNIHCANT RESALE VALUE, AND THE QUESTIONS “WHO USES THIS MOST?” AND “WHO NEEDS THIS MOST?” ARE MORE IMPORTANT THAN “HOW MUCH IS THIS WORTH?” WHEN IT COMES TIME TO DIVIDE THE ITEMS. HOWEVER, THE FOLLOWING INFORMATION SHOULD BE SUPPLIED FOR ITEMSTHAT HAVE INTRINSIC VALUE SUCH AS ANTIQUES, ART, SILVER, AND CRYSTAL.) AS TO ANY PIECE OF FURNITURE OR APPLIANCE WHICH HAS A PRESENT RESALE VALUE IN EXCESS OF $500.00, PLEASE PROVIDE:

 

          ITEM             PURCHASE PRICE              RESALE VALUE        HOW ACQUIRED

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

6. ____________________________________________________________________________

7. ____________________________________________________________________________

 

ESTIMATE RESALE VALUE OF ALL OF YOUR HOUSEHOLD FURNISHINGS AND FIXTURES, EXCLUDING THE ABOVE: $_________________________________________

 

CHECKING ACCOUNTS

 

BANK NAME ON ACCT        PERSON IN CONTROL         ACCT #         AMT IN ACCT

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

 

SAVINGS ACCOUNTS

 

FINANCIAL INSTIT          NAME ON ACCT       PERSON IN CONT        ACCT#            AMT

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

CERTIFICATES OF DEPOSIT (PROVIDE THE SAME INFORMATION AS ABOVE):

 

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

 

DO YOU HAVE THESE?

______________________________________________________________________________

 

WHERE ARE THEY? ___________________________________________________________

______________________________________________________________________________

 

STOCKS, BONDS, AND OTHER SECURITIES:

 

    COMPANY   NAME IN WHICH HELD   #OF SHARES     DATE PURCH       VALUE

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

 

DO YOU HAVE THESE?________________________________________________________

 

WHERE ARE THEY? ___________________________________________________________

______________________________________________________________________________

 

 

INSURANCE

 

                   POLICY #1              POLICY #2              POLICY#3               POLICY #4

 

COMPANY: __________________________________________________________________

POLICY #: ____________________________________________________________________

NAME OF INSD: ______________________________________________________________

OWNER: _____________________________________________________________________

BENEFICIARY: _______________________________________________________________

AMT OF COVER: ______________________________________________________________

AMT OF PREM: _______________________________________________________________

CASH VALUE: ________________________________________________________________

DO YOU HAVE THESE POLICIES? ______________________________________________

WHERE ARE THEY?___________________________________________________________

 

RETIREMENT, PENSION, PROFIT-SHARING, OR OTHER EMPLOYEE BENEFITS

 

EMPLOYER: __________________________________________________________________

 

NAME OR DESCRIPTION OF BENEFIT PLAN: ____________________________________

______________________________________________________________________________

______________________________________________________________________________

 

TOTAL AMOUNT OF EMPLOYEE’S CONTRIBUTIONS TO FUND TO DATE: __________

 

PRIOR TO MARRIAGE $ _______________________________________________________

 

SUBSEQUENT TO MARRIAGE: $ _______________________________________________

 

TOTAL AMOUNT OF EMPLOYER’S CONTRIBUTIONS TO FUND TO DATE: __________

 

PRIOR TO MARRIAGE $ _______________________________________________________

 

SUBSEQUENT TO MARRIAGE: $________________________________________________

 

PRESENT BALANCE OF EMPLOYEE’S INTEREST IN FUND $ ______________________

 

DATE EMPLOYEE IS ENTITLED TO RECEIVE RETIREMENT OR PENSION BENEFITS:

______________________________________________________________________________

 

AMOUNT OF BENEFITS RECEIVABLE PER MONTH ON RETIREMENT: ______________________________________________________________________________

 

BALANCE PAYABLE ON DEATH OF RETIRED EMPLOYEE: _______________________

 

BENEFITS AVAILABLETO EMPLOYEE WITHOUT RETIREMENT: __________________

____________________________________________________________________________________________________________________________________________________________

 

OTHER ASSETS (SPECIFY):

 

ITEM       PURCHASE PRICE HOW ACQUIRED      CURRENT VALUE

 

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

6. ____________________________________________________________________________

7. ____________________________________________________________________________

8. ____________________________________________________________________________

 

PERSONAL INJURY AWARD:

 

          DO YOU OR YOUR SPOUSE HAVE ANY CLAIM PENDING FOR PERSONAL INJURIES, OR HAVE YOU OR YOUR SPOUSE RECEIVED ANY COMPENSATION FOR PERSONAL INJURIES WITHIN THE PAST FIVE YEARS? IF SO, DESCRIBE:

____________________________________________________________________________

____________________________________________________________________________

 

TAX REFUND:

 

ARE ANY TAX REFUNDS EXPECTED?___________________________________________

IF SO, HOW MUCH? $__________________________________________________________

DO YOU HAVE COPIES OF YOUR INCOME TAX RETURNS FOR THE PAST FIVE YEARS? ______________________________________________________________________

 

ACCRUED BONUS, COMMISSIONS:

 

ARE YOU DUE ANY WAGES, BONUSES, COMMISSIONS, OR ACCRUED PAY OF ANY TYPE? IF SO, DESCRIBE: _______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

IS YOUR SPOUSE? ____________________________________________________________

 

IF SO, DESCRIBE: _____________________________________________________________

 

SAFE DEPOSITS BOXES:

 

DO YOU OR YOUR SPOUSE HAVE ACCESS TO A SAFE DEPOSIT BOX? IF SO, DESCRIBE CONTENTS AND WHERE THE BOX IS LOCATED: ______________________

______________________________________________________________________________

 

INSTALLMENT DEBTS:

 

(THIS WILL BE SOMEWHAT REPETITIOUS OF THE INCOME AND EXPENSE STATEMENT. GIVE INFORMATION AS TO ANY INSTALLMENT PAYMENTS OTHER THAN MORTGAGE PAYMENTS, IF ANY, AND REVOLVING CHARGE ACCOUNTS ON WHICH THERE IS A CONTINUING BALANCE. COMMON EXAMPLES INCLUDES LARGE MEDICAL BILLS, BLANK NOTES, AND CAR PAYMENTS.)

 

          CREDITOR     REASON           OUTSTANDING         PAY-OFF                MONTHLY
                             INCURRED         BALANCE               DATE                  PAYMENTS

                   

 

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

6. ____________________________________________________________________________

7. ____________________________________________________________________________

8. ____________________________________________________________________________

9. ____________________________________________________________________________

10. ___________________________________________________________________________

11. ___________________________________________________________________________

12. ___________________________________________________________________________

13. ___________________________________________________________________________

 

SEPARATE PROPERTY INFORMATION

 

1. DESCRIPTION OF ITEM: _____________________________________________________

______________________________________________________________________________

______________________________________________________________________________

NAME IN WHICH HELD: _______________________________________________________

BY WHOM CLAIMED: _________________________________________________________

MANNER OF ACQUISITION (ACQUISITION PRIOR TO MARRIAGE, GIFT FROM WHOM, INHERITANCE FROM WHOM, OR PURCHASE WflH FUNDS OR OTHER PROPERTY WHICH WAS SEPARATE PROPERTY):

 

VALUE AND DEBT:

                    DATE            VALUE OUTSTANDING DEBT         NET VALUE         ACQUISITION: ________________________________________________________________

CURRENT: ___________________________________________________________________

GAIN OR LOSS $: _____________________________________________________________

 

IF INDEBTEDNESS HAS BEEN PAID OFF, IN WHOLE OR PART, DURING MARRIAGE, WHERE DID THE FUNDS USED TO PAY OFF THE INDEBTEDNESS COME FROM?

______________________________________________________________________________

______________________________________________________________________________

 

IS YOUR SPOUSE LIKELY TO DISPUTE YOUR CLAIM THAT THIS ITEM IS SEPARATE PROPERTY? __________________________________________________________________

 

HAS ANY EFFORT BEEN EXPENDED ON SEPARATE PROPERTY? __________________

 

IF SO, THEN DESCRIBE THE EXTENT OF THE COMMUNITY EFFORT EXPENDED, BY

WHOM, WHEN AND ON WHAT:_________________________________________________

____________________________________________________________________________________________________________________________________________________________

 

HAVE ANY COMMUNITY FUNDS BEEN EXPENDED ON THE IMPROVEMENT OF SEPARATE PROPERTY?________________________________________________________

______________________________________________________________________________

 

IF SO, THEN DESCRIBE THE EXTENT; BY WHOM, ON WHAT PROPERTY AND WHEN: ______________________________________________________________________

______________________________________________________________________________

IS YOUR SPOUSE A PRINCIPAL SHAREHOLDER IN ANY BUSINESS?_______________

WHAT TYPE OF BUSINESS? ____________________________________________________

 

WHAT IS THE EXTENT OF THE INTEREST? ______________________________________

 

INCOME AND EXPENSE INFORMATION

 

INCOME

 

PRINCIPAL EMPLOYER AND ADDRESS: ________________________________________

______________________________________________________________________________

JOB TITLE: ___________________________________________________________________

NET MONTHLY INCOME: ______________________________________________________

SECONDARY INCOME SOURCE: _______________________________________________

ADDRESS: ___________________________________________________________________

NET MONTHLY INCOME: ______________________________________________________

TOTAL MONTHLY NET INCOME: _______________________________________________

TOTAL MONTHLY EXPENSES: _________________________________________________

DEFICIT OR SURPLUS: ________________________________________________________

 

ANALYSIS OF INCOME

 

EMPLOYER: __________________________________________________________________

ADDRESS: ___________________________________________________________________

DATE OF EMPLOYMENT: ______________________________________________________

PAY PERIOD: _________________________________________________________________

GROSS PAY: _________________________________________________________________

LESS DEDUCTIONS: __________________________________________________________

INCOME TAX WITHHELD: _______________________________________________

SOCIAL SECURITY: _____________________________________________________

UNEMPLOYMENT: ______________________________________________________

INSURANCE: ___________________________________________________________

MEDICAL OR OTHER: ___________________________________________________

INSURANCE: ___________________________________________________________

RETIREMENT OR PENSION: _____________________________________________

FUND: _________________________________________________________________

          STOCK OPTION OR STOCK: ______________________________________________

PROHT SHARING PLAN: _________________________________________________

SAVINGS PLAN: ________________________________________________________

OTHER: ________________________________________________________________

 

TOTAL DEDUCTIONS: _________________________________________________________

 

BONUS:

TOTAL AMOUNT RECEIVED (AFTER TAX)  ______________________________

ESTIMATED THIS YEAR                                    ______________________________

LASTYEAR                                                     ______________________________

YEAR BEFORE LAST                               ______________________________

DATES WHEN RECEIVED:                      

          DATE _________________ AMOUNT ______________________
          DATE _________________ AMOUNT ______________________
          DATE _________________ AMOUNT ______________________
          DATE _________________ AMOUNT ______________________

 

MONTHLY EXPENSES

 

RENT OR HOUSE PAYMENT                              ______________________________

 

REAL PROPERTY TAXES (IF NOT PART OF MORTGAGE PAYMENT)

 

_____________ UTILITIES:

          GAS                                                              ______________________________

ELECTRICITY AND WATER                     ______________________________

TELEPHONE (INCLUDE LONG DISTANCE) ______________________________

          GROCERIES AND HOUSEHOLD ITEMS                 ______________________________

LUNCHES                                                                ______________________________

MEDICAL AND PRESCRIVII ONS                                   ______________________________

DENTAL                                                                  ______________________________

LAUNDRY & DRY-CLEANING                                       ______________________________

CAR PAYMENT                                                         ______________________________

GASOLINE & VEHICLE MAINT. &

OTHER TRANSPORTATION                               ______________________________

CHILD CARE                                                  ______________________________

iNSURANCE:                                                            ______________________________

CAR                                                             _____________________________ 

HOME (OMIT IF PART OF PAYMENT)                  ______________________________

HEALTH (OMIT IF PAYROLL DEDUCTION) ______________________________

LESSONS FOR CHILDREN (SPECIFY)                            ______________________________

MISCELLANEOUS                                                      ______________________________

OTHER (SPECiFY CREDITOR & ITEM)                          ______________________________

_____________________________                              ______________________________

_____________________________                              ______________________________

_____________________________                              ______________________________

_____________________________                              ______________________________

_____________________________                              ______________________________

 

TOTAL MONTHLY EXPENSES:                                     ______________________________

 

CONSERVATORSHIP INFORMATION

                             (1)                         (2)                         (3)                         (4)

NAME OF CHILD: _____________________________________________________________

SOCIAL SEC. # : _______________________________________________________________

DRIVER’S LICENSE NUMBER AND STATE OF ISSUANCE, IF ANY: ______________________________________________________________________________

BIRTHDATE: _________________________________________________________________

PERSON NOW HAVING ACTUAL CUSTODY:

NAME: _______________________________________________________________________

ADDRESS: ___________________________________________________________________

PHONE: ______________________________________________________________________

LENGTH OF CUSTODY: _______________________________________________________

SCHOOL: ____________________________________________________________________

TEACHER: ___________________________________________________________________

PRINCIPAL: __________________________________________________________________

DOCTOR: ____________________________________________________________________

NAME: ________________________________________________________________

ADDRESS: _____________________________________________________________

PERSONS WITH SPECIAL KNOWLEDGE WHO MAY TESTIFY REGARDING THE CHILDREN:

(CONSIDER RELATIVES, FRiENDS, NEIGHBORS. POLICE OR JUVENILE AUTHORITIES, PSYCHIATRISTS OR PSYCHOLOGISTS, ETC. LIST PERSONS WHOSE TESTIMONY MAY BE UNFAVORABLE OR MERELY PROVIDING BACKGROUND. IN ADDITION TO PERSONS WHOSETESTIMONY MAY BEFAVORABLE.)

 

          NAME/ADDRESS       RELATIONSHIP         LENGTH                 FAVORABLE

          & TELEPHONE         TO CHHLD              OF                         UNFAVORABLE

                                                                   RELATIONSHIP         BACKGROUND

(IDENTIFY WHICH CHILD)

 

1. _____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

2. _____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

3. _____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

4_____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

5. _____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

DESCRIBE ANY SPECIAL PROBLEMS - PHYSICAL, EMOTIONAL, EDUCATIONAL, ETC. - WHICH ANY CHILD MAY HAVE, AND DESCRIBE ATTEMPTS TO COPE WiTH PROBLEMS.

_____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________SHOULD A PSYCHIATRIST OR PSYCHOLOGIST BE REQUESTED TO EXAMINE ANY OF THE CHILDREN? ___________________________________________________________

 

ANY PREFERENCES REGARDING RELIGIOUS UPBRINGING?

          BY YOU? ______________________________________________________________

BY YOUR SPOUSE?____________________________________________________

DO YOU INTEND TO MOVE?___________________________________________________

OUTSIDE COUNTY?_____________________________________________________

OUTSIDE STATE?_______________________________________________________

DOES  YOUR SPOUSE INTEND TO MOVE?_______________________________________

          OUTSIDE COUNTY?_____________________________________________________

          OUTSIDE STATE?_______________________________________________________

IS MARRIAGE PLANNED? _____________________________________________________

          BY YOU? _______________________________________________________________

BY YOUR SPOUSE?______________________________________________________

DOES ANY CHILD HAVE A PREFERENCE AS TO CUSTODY? IF SO, LIST CHILDREN AND PREFERENCE:

_____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

ARE ANY OF THE CHILDREN UNDER THE CONTINUING JURISDICTION OF ANY COURT. AND IF SO, DESCRIBE:

_____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

 

 

IT IS NECESSARY THAT ALL THE CHILDREN HAVE SOCIAL SECURITY NUMBERS. IF THEY DO NOT, THEN THE APPLICATIONS MAY BE OBTAINED AT THE POST OFFICE OR SOCIAL SECURITY OFFICE. YOU MUST ALSO UPDATE THIS INFORMATION IN WRITING AS SOON AS IT NEEDS TO BE UPDATED.