Full Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Former Names
Date of Birth
MM
DD
YYYY
State and/or Country of Birth
*
Level of Formal Education
Are you pregnant?
Do you have any significant medical, mental health or chemical dependency conditions?
If yes, please describe the condition and effects of the condition.
Have you been in military service?
If so, provide the branch and dates of service.
Would you like to change your name after dissolution?
If so, please provide new name.
Occupation / Title & Position
Employer Name and Address
Length of Employment
How many work hours per week?
Does your income include commissions? Please Explain.
Does your income include bonuses? Please Explain.
Does your income include overtime? Please Explain.
ADDITIONAL EMPLOYMENT/INCOME:
Hours worked per week
Health Insurance
Dental Insurance
Vision
Who is covered under the above insurance?
HSA
FSA
Union
Life Insurance. If "Yes," please also provide the value below.
Current Value of Life Insurance
Retirement. If "Yes," please also provide the value below.
Current Value of Retirement
Name of Retirement Plan
Stock Options/Purchase Plan
Company Car
Other (Explain)
Your previous work history and skills:
Full Name
Present Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
Former Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
State and Country of Birth
Is your spouse pregnant?
Level of Formal Education
Does your spouse have any significant medical, mental health or chemical dependency conditions?
If yes, please describe the condition and effects of the condition.
Is or has your spouse been in military service?
If so, provide the branch and dates of service.
Occupation / Title & Position
Employer Name and Address
Length of Employment
How many work hours per week?
Does your spouse's income include commissions? Please Explain.
Does your spouse's income include bonuses? Please Explain.
Does your spouse's income include overtime? Please Explain.
YOUR SPOUSE'S ADDITIONAL EMPLOYMENT/INCOME:
Health Insurance
Dental Insurance
Vision
Who is covered under the above insurance?
HSA
FSA
Union
Life Insurance. If "Yes," please provide the value below.
Current Value of Life Insurance
Retirement. If "Yes," please provide the value below.
Current Value of Retirement
Name of Retirement Plan
Stock Options/Purchase Plan
Company Car
Other (Explain)
If spouse is not employed or works part time, provide spouse's previous work history and skills:
Date of Marriage
MM
DD
YYYY
Place of Marriage
Date of Separation
MM
DD
YYYY
Has there been a separate proceeding commenced for dissolution of marriage, legal separation or custody in the State of Minnesota or elsewhere?
Were YOU previously married?
Full Name of Former Spouse
First Name
Last Name
Date of Marriage
MM
DD
YYYY
Date of Dissolution
MM
DD
YYYY
City and County where Marriage Dissolved
Please provide full names, dates of birth, age, and school grade
Are you receiving support for these children?
Are you paying support for these children?
Are payments current?
Are you paying spousal maintenance (alimony) to a former spouse?
Are payments current?
Please provide full names, dates of birth, age, and school grade
Is your SPOUSE receiving support for these children?
Is your SPOUSE paying support for these children?
Are payments current?
Is your SPOUSE receiving spousal maintenance (alimony)?
Is your SPOUSE paying spousal maintenance (alimony)?
Are payments current?
YOU
Amounts
What county or state provides the public assistance?
YOUR SPOUSE
Amounts
What county or state provides the public assistance?
Homestead
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Titled To:
Date of Purchase
MM
DD
YYYY
Source of Down Payment
Lender (First Mortgage)
Lender (Second Mortgage)
Are mortgage payments current?
Are taxes paid by your mortgage company (escrowed)?
Is your insurance paid by your mortgage company (escrowed)?
Payments Current?
Who presently occupies the house?
Do you desire to be awarded the home?
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Source of Down Payment
Date of Purchase
MM
DD
YYYY
Lender (First Mortgage)
Lender (Second Mortgage)
Are mortgage payments current?
Are taxes paid by your mortgage company (escrowed)?
Is your insurance paid by your mortgage company (escrowed)?
Payments Current?
Do you desire to be awarded this property?
Legal Description
If you or your spouse own additional properties, please provide that information here:
Please provide information about your investments and bank accounts.
Financial Institution | Type of Acct. | Last 4 digits of Acct. No. | Account Balance | Name on Account
Please provide information about your retirement accounts.
Financial Institution | Type of Acct. | Last 4 digits of Acct. No. | Account Balance/Date | Name on Account
Please provide information about your life insurance. If none, state "None."
Company Name | Type of Insurance | Policy No. | Cash Value | Beneficiary | Policy Owner
Please list your stocks and bonds. If none, state "None."
Name of Stock or Bond | Type of Acct. | Number of Shares/Units | Value | Date of Value
List all vehicles
Year | Make | Model | Value | Loan Balance | Registered Owner
Please list your vehicles.
Year | Make | Model | Value | Loan Balance | Registered Owner
Please list your debts. (Loans, Line of Credit, Credit Card, Taxes, etc.)
Creditor | Balance Due | Monthly Payment | Account in Name of: C-Client, S-Spouse, J-Joint
LIST PROPERTY
Item Description | Whose Property | Why It's Non-Marital | Current Value
Do you or your spouse have any stored genetic material?
Are there any pending lawsuits or expected lawsuits involving you or your spouse?
How were you referred to our firm?
Other Notes / Information
