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CLIENT DIVORCE QUESTIONNAIRE
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Law Offices of Donald E. Glass
Phone/Text: (951) 821-8842
Email:  AttorneyPreparedDivorceForms@gmail.com

 

        

PETITIONER          RESPONDENT      
 Full Legal Name        Full Legal Name
 Address  Address
City  City
 State  State
 Zip  Zip
 County  County
 Telephone #  Telephone #
 Date of Marriage:  Date of Separation:
Does Spouse want former name restored? Print FULL Name:

        

 

 

Have you lived in California for the last 6 months? ¨  Yes ¨  No
Have you lived in the County of _____ for the last 3 months? ¨   Yes ¨  No
Have you or your spouse filed for divorce in this marriage before? ¨   Yes ¨  No
Are there any minor children of this marriage? ¨   Yes ¨  No
Is wife pregnant now? ¨   Yes ¨  No
Are there any minor children adopted during this marriage? ¨   Yes ¨  No
Is your spouse in active military service? ¨   Yes ¨No

 

 

PETITIONER RESPONDENT      
 Date of Birth              Date of Birth
 Social Security #  Social Security #
 Driver’s License #  Driver’s License #
 Employer Name  Employer Name
 Employer Address  Employer Address
 City City
State  State
 Zip  Zip
Employer Telephone # Employer Telephone #
Monthly Salary/Wages Income: $

Commissions: $

Public Assistance: $

Spousal Support: $

Other Income: $

Monthly Salary/Wages Income: $

Commissions: $

Public Assistance: $

Spousal Support: $

Other Income: $

Occupation: Occupation:
Date Job Started:
If Unemployed, Date Job Ended
Date Job Started:
If Unemployed, Date Job Ended
Self-Employment Income: $ Self-Employment Income: $
 

Average Monthly Expenses

Rent: $

Mortgage:$

Real Property Taxes: $
Maintenance/Repairs: $ Health-care: Out of Pocket: $
Child Care: $

 

Groceries & Supplies: $
Teleehone, Cell, email: $ Utilities
(gas, electric, water, trash): $
Eating Out: $ Laundry / cleaning: $
Clothes: $ Education: $
Auto
( insurance, gas, repairs, bus, etc): $
Insurance ( life & accident only): $
Other expenses: $ Other expenses: $

 

 

 

 

ASSETS Gross $$ Debt $$ Net $$ Proposal for Division:
Award to:
Brief Description Date Acquired Gross Fair Mkt Value Amount of Debt Net Fair Mkt Value Petitioner Respondent
Real Estate

 

Furniture

 

Appliances

 

Jewelry

 

Antiques

 

Art, etc

 

Vehicles

 

Boats, etc.

 

Savings

Accts

Checking

Accts

Credit Union
Cash
Tax Refund
Life Insur w/cash value
Stocks, bonds, Mutual Funds
Retirement

Accts

Pension
Profit

Sharing,

IRAs, Etc.

Accts

Receivable

Business

Interests

 

 

Other Assets

 

 

 

 

 

SEPARATE PROPERTY

(Property you acquired before marriage or after separation)

 

 NAME of ITEM  –  $$  VALUE  –  Date you Acquired           WHO  RECEIVES- You or Spouse

1.   _____________________________________________________________________                                                                                                       

2.  ______________________________________________________________________                                                                                                          

3. ______________________________________________________________________                                                                                                              

4.  ______________________________________________________________________                                                                                                           

5.   ______________________________________________________________________

   6.  ______________________________________________________________________

   7.  ______________________________________________________________________

 

 

 

DEBTS

  Owed To Date Incurred Total Owing Proposal for Division –
Award to:
Petitioner Respondent
Loans-Unsecured

 

 

 

 

 

Credit Cards

 

 

 

 

 

 

 

 

 

 

Student Loans

 

 

Taxes

 

 

Minor Children of the Parties – Children of the marriage or adopted children:                                        

  Name/City of Birth Social Security Number Date of  Birth Age

 

Sex

 

Presently Living

               with

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

Location of the Minor Children for the last 5 years
From – To               Address                                                   Lived with Whom1.    __________________________________________________________________________2.    __________________________________________________________________________3.    __________________________________________________________________________4.    __________________________________________________________________________ 

 

 

 

 

Child Custody To Be Awarded (Check one box in A and one box in B)

 

 

              A. LEGAL CUSTODY

            B. PHYSICAL CUSTODY
 

¨   Joint to Petitioner & Respondent

 

¨   Joint to Petitioner & Respondent

 

¨   Sole to Petitioner

 

¨   Sole to Petitioner

 

¨  Sole to Respondent

 

¨  Sole to Respondent

 

 


Child Visitation Rights to Be Granted
(Select One)¨  Reasonable ¨  Other (specify) Child Support To Be Awarded to  ¨  Petitioner   ¨  Respondent    ¨  Reserved Amount Requested: $_________ Payable on the ______ day of each month Is Husband or Wife currently receiving TANF, SSI, SOCIAL SECURITY,OTHER?                                                                                   ¨ Yes     ¨ NoIs Wife currently applying for TANF (welfare)?                             ¨ Yes     ¨ No

(If  WIFE is receiving TANF the DCSS office will set the amount of child support)

 

HEALTH INSURANCE

Does your Job have Child Health Insurance Available to you? ¨Yes ¨ No
Cost per Month $_______
Name of Insurance Co:
Address:

Who is responsible for paying the deductible on insurance?  ¨ Husband   ¨ Wife

 

Should Spousal Support be awarded?
¨Husband   ¨Wife    ¨Reserved    ¨Waived

 

 

Amount of Spousal Support has been agreed to by both parties at $___________                   per month for a period of                                _ or until party remarries, cohabitates or dies.

 

 

Retirement Benefits should be awarded to ¨Husband   ¨Wife   ¨Reserved   ¨Waived (If retirement benefits are awarded and party needs a JOINDER and QDRO – there will be an additional charge.)

                                                                                                                                                        

 

 

 


ADDITIONAL INFORMATION OR COMMENTS
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 


                           ACKNOWLEDGMENT AND AUTHORIZATION

I declare that the foregoing information which I have provided is, to the best of my knowledge, true and correct.

 

Date:_________                                   Signature:__________________________________

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