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* Date Format: MM slash DD slash YYYY SECTION I – CLIENT INFORMATIONName*Date of Birth* Date Format: 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:*CurrentMailingCellWorkHomeWhich telephone number to do prefer we use to contact you?*CellWorkHomeThis E-Mail Address is secure (private to you)?*YesNoAre you or have you ever been a member of the military service?*YesNoBranchRank/Pay/GradeDates of ServiceRetired/RankHave you consulter or retained any other attorney on this matter before coming to this office?*YesNoIf 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-timePart-timeDays*Hours*YOUR CURRENT INCOME INFORMATION:*SalariedHourlyAnnual Salary*Hourly Rate*Pay Periods*WeeklyBi-Weekly (26/yr)Bi-Monthly (24/yr)MonthlyBonuses?*YesNoHow many per year?*Average bonus $*Other income sources, if so what?401k?*YesNoPension?*YesNoDeferred Comp?*YesNoHealth Insurance?*YesNoCost per period for self?*Cost per period for child?*Dental Insurance?*YesNoVision Insurance?*YesNoCar Allowance?*YesNoYOUR 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* Date Format: 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?*YesNoBranchRank/Pay GradeDates of ServiceRetired/RankOTHER PARTY’S CURRENT EMPLOYMENT INFORMATION:Employer*Title/Position*Address*Date Started**Full-timePart-timeDays*Hours*OTHER PARTY’S INCOME INFORMATION:*SalariedHourlyAnnual Salary*Hourly Rate*Pay Periods*WeeklyBi-Weekly (26/yr)Bi-Monthly (24/yr)MonthlyBonuses?*YesNoHow many per year?Average bonusOther income sources, if so what?401k?*YesNoPension?*YesNoDeferred Comp?*YesNoHealth Insurance?*YesNoCost per period for self?*Cost per period for child?*Dental Insurance?*YesNoVision Insurance?*YesNoCar Allowance?*YesNo 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* Date Format: MM slash DD slash YYYY Place*Are you & your spouse separated?*YesNoDate of Separation* Date Format: MM slash DD slash YYYY Length of residence in*County:*Length of residence in State of Iowa:*Do you want marriage counseling?*YesNoDoes your insurance cover the cost?*YesNoHas anyone filed a prior action?*YesNoIf so, when?*Where?*Your attorney in prior action*Other party’s attorney*What was the outcome?*Date Decree/Order Entered* Date Format: MM slash DD slash YYYY Do you need a restraining order?*YesNoTo protect self?YesNoProperty?YesNoIf so, describe specific reasonsHow many prior marriages (you)*How many prior marriages (other party)*SECTION IV – PRENUPTIAL AGREEMENTSIs there a premarital agreement?*YesNoDate of Agreement* Date Format: 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 Date Format: MM slash DD slash YYYY SexMFSocial Security NumberPlace of BirthGeneral HealthGrade/SchoolChild 2 Full NameDate of Birth Date Format: MM slash DD slash YYYY SexMFSocial Security NumberPlace of BirthGeneral HealthGrade/SchoolChild 3 Full NameDate of Birth Date Format: MM slash DD slash YYYY SexMFSocial 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 withYou onlyYou & other parentFromUntilChildren resided at (address)Resided withYou onlyYou & other parentFromUntilChildren resided at (address)Resided withYou onlyYou & other parentFromUntilChildren resided at (address)Resided withYou onlyYou & other parentNames 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 Date Format: MM slash DD slash YYYY SexMFSocial 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
