THIS FORM IS DESIGNED AND CREATED TO ASSIST YOUR ATTORNEY IN DRAFTING YOUR SEPARATION AGREEMENT.

IT SHOULD
NOTAND IS NOT INTENDED TO CONSTITUTE LEGAL ADVICE. ONLY YOUR ATTORNEY CAN OFFER LEGAL ADVICE CONCERNING
YOUR CASE. SHOULD YOU HAVE ANY QUESTIONS ABOUT YOUR SITUATION, PLEASE CONTACT YOUR ATTORNEY IMMEDIATELY.

STIPULATION AND PROPERTY SETTLEMENT AGREEMENT

INFORMATION FORM

POTENTIAL CLIENT: _________________________ CONTACT NUMBER: _________________

HUSBAND’S INFORMATION
Full Name: ___________________________________________________________________________
Address: _____________________________________________________________________________
Home Telephone: ____________________ Social Security Number: _____________________________
Date of Birth: __________________________ Place of Birth: __________________________________
Highest Level of Education: ___________ (Primary 0-12 years) ___________ (Secondary 1-8 years)
Employer: ____________________________________________________________________________
Employer’s Address: ___________________________________________________________________
Work Telephone Number: _______________________________________________________________
Is Husband in the military? ______________________________________________________________
If so, what branch: _____________________________________________________________________
What was the date of entry: ________________ What is the date of separation from military: _________
Has Husband been a resident of Virginia for the past six months? ________________________________
If no, when did he move to Virginia? ______________________________________________________
Who is responsible for providing Husband’s health insurance? __________________________________
Who is responsible for Husband’s unpaid medical expenses, including prescriptions? ________________
WIFE’S INFORMATION
Full Name (including maiden name): ______________________________________________________
Address: _____________________________________________________________________________
Home Telephone: ____________________ Social Security Number: _____________________________
Date of Birth: __________________________ Place of Birth: __________________________________
Highest Level of Education: ___________ (Primary 0-12 years) ___________ (Secondary 1-8 years)
Employer: ____________________________________________________________________________
Employer’s Address: ___________________________________________________________________
Work Telephone Number: _______________________________________________________________
Is Wife in the military? _________________________________________________________________
If so, what branch: _____________________________________________________________________
What was the date of entry: ________________ What is the date of separation from military: _________
Has Wife been a resident of Virginia for the past six months? ___________________________________
If no, when did she move to Virginia? ______________________________________________________
Who is responsible for providing Wife’s health insurance? _____________________________________
Who is responsible for Wife’s unpaid medical expenses, including prescriptions? ___________________

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

MARRIAGE INFORMATION
Date of marriage: _____________________________________________________________________
City and state of marriage: _____________________________________________________________
Date separated: ______________________________________________________________________
Last place you lived with your spouse: ____________________________________________________

CHILD(REN) INFORMATION
Number of child(ren) born of this marriage: _________________________________________________
Number of child(ren) adopted during the marriage: ___________________________________________
Are any child(ren) anticipated at this time? __________________________________________________

Child(ren)’s Name(s) and Social Security Number(s): Date of Birth:

_______________________________________________________ _____________________________
_______________________________________________________ _____________________________
_______________________________________________________ _____________________________
_______________________________________________________ _____________________________

Which parent is to have physical custody of the child(ren)? ______________________________

Visitation schedule: _____________________________________________________________

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

Is there any reason that one of you should not have legal custody?___________________________
If so, what is that reason? _________________________________________________________
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

Parents may be entitled to certain tax benefits relating to the children. Is there any agreement
regarding who gets these benefits? _________________________________________________
If so, what is that agreement: ______________________________________________________
_____________________________________________________________________________
_
_____________________________________________________________________________
_

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

Who provides for health insurance? ________________________________________________

Who is responsible for unpaid medical expenses, including prescriptions? _________________________
Are there any extraordinary medical expenses? _______________________________________
Do you have an agreement regarding child support and, if so, what is that agreement?
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

_____________________________________________________________________________
____
Child support in Virginia is calculated pursuant to Virginia Code Section 20-108.2. These are
referred to as the Guidelines. If you are not following the Guidelines, you must provide a specific
reason for the deviation. In the event that you and your spouse are not following the Guidelines,
please state your reason for the deviation.
_______________________________________________
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
Page 5 of 9
FINANCES
It is extremely important all of your debts and assets be listed so that they can be disposed of in
the
divorce process. As such, please disclose them below fully and accurately. Be sure to note any
and
all joint debts and who is to be responsible so that those debts can be enforced in the
bankruptcy.

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

If a debt is not listed and addressed, you may be solely responsible for that debt if your spouse
fails
to make the necessary payment(s).
Are there any bank accounts (of any sort) which need to be divided?
_________________________
If so, please state the following:
Name of Bank
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Type of Account
________________
________________
________________
________________
________________
________________
________________
________________
________________
Estimated Amount
________________
________________
________________
________________

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

________________
________________
________________
________________
________________
How Divided?
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Do you own or rent a home? _________________ Monthly payment? ______________
Whose name is the home in? ______________________________________________________
What is the street address of the home?
________________________________________________
What is to be done with the home? (Example, Husband will by out Wife’s interest, house will be
sold and the equity split equally, etc.)
________________________________________________
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
Page 6 of 9
Do you and your spouse jointly own any motor vehicles?
__________________________________
If so, please state the following:
Type of Vehicle
___________________
___________________
___________________
___________________
___________________
___________________
Any Debt
________________
________________
________________
________________
________________
________________
Estimated Amount

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

________________
________________
________________
________________
________________
________________
How Divided/Who Pays?
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Do you and your spouse have any other debt?
___________________________________________
If so, please state the following:
Creditor
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Type of Debt
________________

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Estimated Amount
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
How Divided/Who Pays?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

Is there any agreement regarding spousal support?_____________________________________

If so, what is it?______________________________________________________________
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
_____________________________________________________________________________
____
Page 7 of 9

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

Is there any other property (personal or real) that needs to be divided?
_________________________
If so, please state the following:
What Property
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
How Divided/Who Pays?
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Page 8 of 9
What has been omitted that need to be addressed?

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

 VS4 - REPORT OF DIVORCE OR ANNULMENT
With any final divorce decree, a VS4 form must be filed. This is reported to the Department of
Health so that it can track divorces as well as marriages. Please answer these questions below so
that we can submit a VS4.
HUSBAND

Full Name: ____________________________________________________________________

Social Security Number: _________________________________________________________
Race: ________________________________________________________________________
Place of Birth: _______________________________________________ (State or Foreign Country)
Date of Birth: __________________________________________________________________
Number of This Marriage: ___________________________________________(First, Second, etc.)
Education: ___________________________________________________ (Highest level completed)
Usual Residence: _______________________________________________________________

WIFE
Full Name (include maiden name): _________________________________________________
Social Security Number: _________________________________________________________
Race: ________________________________________________________________________
Place of Birth: _______________________________________________ (State or Foreign Country)
Date of Birth: __________________________________________________________________
Number of This Marriage: ___________________________________________(First, Second, etc.)
Education: ___________________________________________________ (Highest level completed)
Usual Residence: _______________________________________________________________
MARRIAGE/DIVORCE
Place of Marriage: ____________________________________________ (State or Foreign Country)
Date of Marriage: _______________________________________________________________
Number of children under the age of 18 in this family: __________________________________
Number of children under 18 in this family whose physical custody was awarded to:
_______________ Husband _______________ Wife
_______________ Joint _______________ Other  No children

©Brian A. Thomasson, Esq. 2010 Page 1 of 9

Date of Separation: _____________________________________________________________

©Brian A. Thomasson, Esq. 2010 Page 1 of 9