Personal information in the marriage of

There are additional pages attached to this worksheet Date:

ABOUT THE MARRIAGE

1. Date of marriage: Place of marriage:
City State

2. Date of separation:
(when one of us left the marital bed or at least clearly said the marriage was over)

3. I have resided in (state) for years and in the County of for years.

My spouse resided in for years and in the County of for years.

4. The divorce is desired by: ___ Husband __ Wife

5. There are children born or adopted into this marriage (further information below).

6. __ There are issues of domestic abuse, violence or harassment in this case (describe briefly):

ABOUT MYSELF
7. Name:

8. Telephones: Home:

Work: __ OK to phone at work

Other: __ OK to leave message

9. Sex: Age: Date of birth:

10. Mailing address:

Street City State Zip

Residence address:
Street City State Zip

County of residence: How long?

11. Former name(s):

12. __ I do not wish a former name restored.

__ I want my former name restored as follows:

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13. Employer (name):

Address:
Street City State Zip

Days and times at work:

Length of this employment: Approximate monthly gross pay: $

There is medical / dental coverage through my employer:

__for me __for my spouse __for children Monthly cost: $

My Social Security number:

Cost of child care enabling me to work is $ per month.

14. Other sources of income: Approx. amount per month:

a) $

b) $

c) $

15. Health problems for which special attention or care is necessary:

16. Other than my spouse or children, I am currently residing with:

Name Age Relationship to me

Monetary arrangements with the above persons:

17. __ I have no will. __ My most recent will was made on (date):

ABOUT MY SPOUSE
18. Name:

19. Telephones: Home:

Work: __OK to phone at work

Other: __OK to leave message

20. Sex: Age: Date of birth:

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21. Mailing address:
Street City State Zip

Residence address:
Street City State Zip

County of residence: How long?

22. Former name(s):

23. __ Spouse does not wish a former name restored.
__ Spouse wants former name restored as follows:

24. Employer (name):

Address:
Street City State Zip

Days and times at work:

Length of this employment: Approximate monthly gross pay: $

There is medical / dental coverage through spouse’s employer:
__ for me __ for spouse __ for children Monthly cost: $

Spouse’s Social Security number:

Cost of child care enabling spouse to work is $ per month.

25. Other sources of income: Approx. amount per month:
a) $

b) $

c) $
26. Health problems for which special attention or care is necessary:

27. Other than children of me and my spouse, my spouse currently resides witth: __ no one __ don’t know
Name Age Relationship to me

Monetary arrangements with the above persons is: __ known __ suspected

28. Spouse's attorney is:

Address:

Phone: Fax: Email:

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CHILDREN BORN OR ADOPTED INTO THIS MARRIAGE
29. Name Age Birthdate Social Security # Residing with

There is is not likely to be any dispute about the paternity of any of the children.
30. Special health care problems:

31. Income or property owned by any dependent children:

32. Custody and visitation of children:

a) is currently arranged and is working out as follows:

b) I want the judgment to order custody and visitation rights as follows:

c) I anticipate that there __ will __ will not be a dispute over custody and visitation.

MY PREVIOUS MARRIAGES & RELATIONSHIPS

33. I was previously married times before this marriage.
Name of my former spouse(s) When terminated How (death, divorce, etc.)

a)

b)

c)

34. My children born or adopted into previous marriage(s):

Name Age Birthdate Residing with

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35. My children from a non-marital relationship:
Name Age Birthdate Residing with

36. Support paid or received by me or by the above children, or other income (such as Social
Security) received by or on behalf of the above children, is as follows:

Support that is owed to me or owed by me that is in arrears (give amount and explain):

MY SPOUSE'S PREVIOUS MARRIAGES & RELATIONSHIPS

37. My spouse was previously married times before this marriage.

Name of former spouse(s) When terminated How (death, divorce, etc.)

a)

b)

c)

38. My spouse's children born or adopted into the previous marriage(s):

Name Age Birthdate Residing with

39. My spouse's children from a non-marital relationship:

Name Age Birthdate Residing with

40. Support paid or received (including any overdue) by my spouse or by the above children, or other income (such as
Social Security) received by or on behalf of the above children, is as follows:

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CURRENT ARRANGEMENTS
41. __ We are not yet separated.
__ We are separated but have no financial arrangements at this time.
__ We have separated and now live apart under the following financial arrangements:
Direct payments (mortgage, bills, etc.)
Who pays? Item Amount How often paid

Other arrangements:

42. __ We have made no written agreements and have no oral understandings.

__ We have a written agreement which is attached.
__ We have oral agreements or understandings as follows:

PENDING ISSUES AND QUESTIONS

43. I foresee the following problems in dealing with my spouse (i.e., fear, distrust, dishonesty,
unwillingness to compromise, using children as a weapon, violence, etc.):

44. I have some questions and issues I would like to explore, as follows:

45. I have already made some decisions about what outcome I would like with respect to property,
children, support, or goals and conduct of this case, as follows:

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