Delaney's Law Firm - Divorce Intake Form

intake

Intake Form- enter the information below and submit the form. After you've completed the form but before clicking submit, you may want to print the form out.

Part I: Personal Information

Client	Client's Spouse
Name:	Name:
Address:	Address:
City and Province:	City and Province:
Postal Code:	Postal Code:
Home Phone:	Home Phone:
Work Phone:	Work Phone:
Fax:	Fax:
Cell/Pager:	Cell/Pager:
E-mail Address:	E-mail Address:
Resident in (municipality and province):	Resident in (municipality and province):
Since (date):	Since (date):
Birthday:	Birthday:
Surname at Birth:	Surname at Birth:
Surname just before marriage:	Surname just before marriage:
Divorced before (yes or no)?	Divorced before (yes or no)?
If divorced before, place/date of previous order:	If divorced before, place/date of previous order:
Spouse's lawyer's name:
Payor's mother's maiden name:

Relationship Dates
Date married:

Place married:

Date started living together:

Date separated:

Still living together (yes or no)?

Reconciliation date (if any):

Information About Your Children:

List each child's full legal name, age, birth date, place of residence, the name of the person they are now living with and the relationship to the child:

Previous cases or agreements:

Have you or the children been in a court case before? Yes No

If yes, please provide the details:

Have you made a written agreement dealing with any matter involved in this case? Yes No

If yes, please provide the details (including the dates of any agreements):

Part II. Financial Information

Assets and Debts (as of date of separation):

House (market value)

Outstanding mortgage balance:

Pension value:

Spouse's pension value:

Investment Assets:

Spouse's Investment Assets:

Joint Investment Assets:

Auto value:

Spouse's auto value:

Debts:

Spouse's Debts:

Joint Debts:

Assets and Debts (as of date of marriage):

Value of Assets:

Spouse's Assets:

Debts:

Spouse's Debts:

Joint Debts:

Assets Received During Marriage:

Value of inheritances or gifts received or proceeds of life insurance received:

Value of spouse's inheritances or gifts received or proceeds of life insurance received:

Client's Income Info:	Spouse's Income Info:
Annual income from employment:	Annual income from employment:
Income from other sources:	Income from other sources:
Job description:	Job description:
Employer:	Employer:
Employer's address:	Employer's address:
Social insurance number:	Social insurance number:
Employee number:	Employee number:

Issues:

Issue	In dispute?
Custody	Yes No Not Sure
Access	Yes No Not Sure
Child support	Yes No Not Sure
Spousal support	Yes No Not Sure
Equalization of assets	Yes No Not Sure

Other issues: