Client Intake InformationTYPE OF CASE* Divorce with children (complete Sections I-VI) Paternity or Child Custody action (complete Sections I, II, V & VI) Modification of Prior Decree/Order (complete Sections I, II, V & VI) Contempt or Enforcement Action (complete Sections I, II, V & VI) Cohabitation with ChildrenDate* MM slash DD slash YYYY SECTION I – CLIENT INFORMATIONName*Date of Birth* MM slash DD slash YYYY Maiden/Former NamePlace of Birth*Social Security Number*Current Address*City / State / Zip / County*Mailing Address*If we must send something to you outside of email, we can send it to:* Current MailingCellWorkHomeWhich telephone number to do prefer we use to contact you?* Cell Work HomeThis E-Mail Address is secure (private to you)?* Yes NoAre you or have you ever been a member of the military service?* Yes NoBranchRank/Pay/GradeDates of ServiceRetired/RankHave you consulter or retained any other attorney on this matter before coming to this office?* Yes NoIf yes, with whom and when?By whom were you referred to this law firm?YOUR CURRENT EMPLOYMENT INFORMATION:Employer*Title/Position*Address*Date Started** Full-time Part-timeDays*Hours*YOUR CURRENT INCOME INFORMATION:* Salaried HourlyAnnual Salary*Hourly Rate*Pay Periods* Weekly Bi-Weekly (26/yr) Bi-Monthly (24/yr) MonthlyBonuses?* Yes NoHow many per year?*Average bonus $*Other income sources, if so what?401k?* Yes NoPension?* Yes NoDeferred Comp?* Yes NoHealth Insurance?* Yes NoCost per period for self?*Cost per period for child?*Dental Insurance?* Yes NoVision Insurance?* Yes NoCar Allowance?* Yes NoYOUR EMPLOYMENT HISTORY (recent to oldest):EmployerTitle/PositionAddressDates of EmploymentEmployerTitle/PositionAddressDates of EmploymentEmployerTitle/PositionAddressDates of EmploymentEDUCATIONHigh SchoolCollegeGraduate SchoolOther Training/Certification/LicensesSECTION II – SPOUSE/OPPOSING PARTY INFORMATIONName*Date of Birth* MM slash DD slash YYYY Maiden/Former NamePlace of Birth*Social Security Number*Current Address*City / State / Zip / County*Are they (or have they ever been) a member of the military service?* Yes NoBranchRank/Pay GradeDates of ServiceRetired/RankOTHER PARTY’S CURRENT EMPLOYMENT INFORMATION:Employer*Title/Position*Address*Date Started** Full-time Part-timeDays*Hours*OTHER PARTY’S INCOME INFORMATION:* Salaried HourlyAnnual Salary*Hourly Rate*Pay Periods* Weekly Bi-Weekly (26/yr) Bi-Monthly (24/yr) MonthlyBonuses?* Yes NoHow many per year?Average bonusOther income sources, if so what?401k?* Yes NoPension?* Yes NoDeferred Comp?* Yes NoHealth Insurance?* Yes NoCost per period for self?*Cost per period for child?*Dental Insurance?* Yes NoVision Insurance?* Yes NoCar Allowance?* Yes No OTHER PARTY’S EMPLOYMENT HISTORY (recent to oldest):EmployerTitle/PositionAddressDates of EmploymentEmployerTitle/PositionAddressDates of EmploymentEmployerTitle/PositionAddressDates of EmploymentEDUCATIONHigh SchoolCollegeGraduate SchoolOther Training/Certification/LicensesSECTION III – MARRIAGE INFORMATIONDate of Marriage* MM slash DD slash YYYY Place*Are you & your spouse separated?* Yes NoDate of Separation* MM slash DD slash YYYY Length of residence in*County:*Length of residence in State of Iowa:*Do you want marriage counseling?* Yes NoDoes your insurance cover the cost?* Yes NoHas anyone filed a prior action?* Yes NoIf so, when?*Where?*Your attorney in prior action*Other party’s attorney*What was the outcome?*Date Decree/Order Entered* MM slash DD slash YYYY Do you need a restraining order?* Yes NoTo protect self? Yes NoProperty? Yes NoIf so, describe specific reasonsHow many prior marriages (you)*How many prior marriages (other party)*SECTION IV – PRENUPTIAL AGREEMENTSIs there a premarital agreement?* Yes NoDate of Agreement* MM slash DD slash YYYY Attorney who drafted the agreement*Name of other attorney, if oneIf you have a copy, please bring this to your appointment.SECTION V – CHILDRENCHILDREN OF THIS RELATIONSHIPPlease list the full name, date and place of birth, sex, social security number, year/grade, school/college, and health of each child born to or adopted into this relationship.Child 1 Full NameDate of Birth MM slash DD slash YYYY Sex M FSocial Security NumberPlace of BirthGeneral HealthGrade/SchoolChild 2 Full NameDate of Birth MM slash DD slash YYYY Sex M FSocial Security NumberPlace of BirthGeneral HealthGrade/SchoolChild 3 Full NameDate of Birth MM slash DD slash YYYY Sex M FSocial Security NumberPlace of BirthGeneral HealthGrade/SchoolList the addresses at which the minor children of THIS relationship have lived for the past five (5) years, and with whom they have lived. You need only go back five (5) years from the current month.FromUntilChildren resided at (address)Resided with You only You & other parent FromUntilChildren resided at (address)Resided with You only You & other parent FromUntilChildren resided at (address)Resided with You only You & other parent FromUntilChildren resided at (address)Resided with You only You & other parent Names and ages of any other minor children not born to or adopted into this relationship, their other parent, and custody arrangements.Child NameDate of Birth MM slash DD slash YYYY Sex M FSocial Security NumberParent NameGrade/SchoolCustodial ParentChild 2 NameDate of BirthSexSocial Security NumberParent NameGrade/SchoolCustodial ParentSECTION VI – ISSUES OF CONCERN* Custody of children or visitation Division of Property & Debts Child Support Alimony/Spousal Support Gifted or Inherited Property Valuation of Business Interests Payment of Household Bills or possession of home Restraining Order to Protect Assets Removal of children from state or U.S. by other parent Health Insurance for self or children Payment of College Tuition Restraining Order – Domestic AbuseOther
