CONFIDENTIAL DISSOLUTION WORKSHEET

I. CLIENT’S PERSONAL DATA

A. IDENTIFICATION

NAME:

 

                          First                                                                                                               MI                                                                       Last

MAIDEN NAME (if different):

 

MOTHER’S MAIDEN NAME:

 

ADDRESS:

 

CITY:

 

COUNTY:

 

STATE:

 

ZIP:

 

WORK PHONE:

 

HOME PHONE:

 

BIRTH DATE:

 

BIRTH STATE:

 

SOC. SEC. NUMBER:

 

DRIVER’S LIC. NO:

 

 

SEX

RACE

HEIGHT

WEIGHT

EYE COLOR

HAIR COLOR

 

B. UNEMPLOYMENT

WHEN DID YOU LAST WORK (MONTH/YEAR)?

 

WHAT WERE YOUR GROSS MONTHLY EARNINGS?

 

WHY ARE YOU PRESENTLY UNEMPLOYED?

 

 

C. EMPLOYER

EMPLOYER:

 

ADDRESS:

 

WORK HOURS OF EMPLOYMENT:

 

TITLE/POSITION:

 

LENGTH OF EMPLOYMENT:

 

DATE YOU COMMENCED EMPLOYMENT WITH EMPLOYER:

 

 

D. EDUCATION/SKILLS

EDUCATION (Highest level completed):

 

WERE YOU MARRIED TO PRESENT SPOUSE WHILE ATTENDING SCHOOL?

c YES

c NO

VOCATIONAL SKILLS:

 

DATE YOUR SKILLS LAST USED:

 

 

E. HEALTH

STATE OF HEALTH:

 

DOCTORS CURRENTLY BEING SEEN:

 

MEDICATIONS CURRENTLY BEING TAKEN:

 

 

F. MILITARY

ARE YOU IN THE MILITARY:

c YES

c NO

BRANCH:

 

RANK:

 

 

G. MARRIAGE

DATE OF MARRIAGE:

 

COUNTY MARRIAGE IS REGISTERED IN:

 

LOCATION OF MARRIAGE:

 

                                                                                         City                                                                                              County                                                                                              State

SEPARATED:

c YES

c NO

DATE SEPARATED:

 

WHO LEFT RESIDENCE?

 

WERE YOU PREVIOUSLY MARRIED?

c YES

c NO

IF YES, DATE TERMINATED:

 

IS RECONCILIATION A POSSIBILITY?

c YES

c NO

HAVE YOU/YOUR SPOUSE CONSULTED A MARRIAGE COUNSELOR?

c YES

c NO

IF YES, WHO?

 

DO YOU THINK YOUR SPOUSE WILL RESIST THIS DISSOLUTION OR LEGAL SEPARATION?

c YES

c NO

DO YOU DESIRE THAT WE REQUEST YOUR SPOUSE HAVE TO PAY YOUR ATTORNEY FEES?

c YES

c NO

DO YOU THINK YOUR SPOUSE WILL AGREE TO SIGN A SEPARATION CONTRACT TO DIVIDE YOUR PROPERTY?

c YES

c NO

WILL THERE BE A NAME CHANGE INVOLVED IN THIS ACTION?

c YES

c NO

IF YES, PLEASE GIVE NAME DESIRED:

 

DO YOU NEED A TEMPORARY RESTRAINING ORDER TO PROTECT YOURSELF AND YOUR CHILD(REN) FROM YOUR

SPOUSE?

c YES

c NO

WILL YOU NEED A TEMPORARY ORDER WHICH REQUIRES YOUR SPOUSE TO PAY YOU MONTHLY  MAINTENANCE

PAYMENTS?

c YES

c NO

IS THERE ANYTHING ELSE THAT I SHOULD KNOW REGARDING YOUR MARRIAGE AND WHAT PROBLEMS HAVE

OCCURRED?

 

 

 

 

 

II. SPOUSE’S PERSONAL DATA

A. IDENTIFICATION

NAME:

 

                          First                                                                                                               MI                                                                       Last

MAIDEN NAME (if different):

 

MOTHER’S MAIDEN NAME:

 

ADDRESS:

 

CITY:

 

COUNTY:

 

STATE:

 

ZIP:

 

WORK PHONE:

 

HOME PHONE:

 

BIRTH DATE:

 

BIRTH STATE:

 

SOC. SEC. NUMBER:

 

DRIVER’S LIC. NO:

 

 

SEX

RACE

HEIGHT

WEIGHT

EYE COLOR

HAIR COLOR

 

B. UNEMPLOYMENT

WHEN DID HE/SHE LAST WORK (MONTH/YEAR)?

 

WHAT WERE HIS/HER GROSS MONTHLY EARNINGS?

 

WHY IS HE/SHE PRESENTLY UNEMPLOYED?

 

 

 

C. EMPLOYER

EMPLOYER:

 

ADDRESS:

 

WORK HOURS OF EMPLOYMENT:

 

TITLE/POSITION:

 

LENGTH OF EMPLOYMENT:

 

DATE HE/SHE COMMENCED EMPLOYMENT WITH EMPLOYER:

 

APPROXIMATELY HOW MANY EMPLOYEES ARE EMPLOYED BY SPOUSES EMPLOYER?

 

 

D. EDUCATION/SKILLS

EDUCATION (Highest level completed):

 

WAS HE/SHE MARRIED TO YOU WHILE ATTENDING SCHOOL?

c YES

c NO

VOCATIONAL SKILLS:

 

DATE HIS/HER SKILLS WERE LAST USED:

 

 

E. HEALTH

STATE OF HEALTH:

 

DOCTORS CURRENTLY BEING SEEN:

 

MEDICATIONS CURRENTLY BEING TAKEN:

 

 

F. MILITARY

IS SPOUSE IN THE MILITARY:

c YES

c NO

BRANCH:

 

RANK:

 

 

III. CHILDREN OF MARRIAGE

A. CHILDREN OF THIS MARRIAGE (Include Adoptions)

Full Legal Name

Age and Date of Birth

Living With

 1.

 

 

 

 2.

 

 

 

 3.

 

 

 

 4.

 

 

 

 5.

 

 

 

 6.

 

 

 

 

DO ANY OF THESE CHILDREN NO LONGER REQUIRE SUPPORT?

c YES

c NO

IF YES, LIST NAMES AND REASONS:

 

 

 

ARE ANY CHILDREN HANDICAPPED OR IN POOR PHYSICAL HEALTH?

c YES

c NO

IF YES, PLEASE NAME AND BRIEFLY EXPLAIN:

 

 

 

IS WIFE NOW PREGNANT?

c YES

c NO

DO YOU ANTICIPATE ANY PROBLEMS WITH CUSTODY OR VISITATION?

c YES

c NO

IF YES, EXPLAIN:

 

 

HAVE ANY OF YOUR CHILDREN EVER SEEN A SOCIAL WORKER, PSYCHOLOGIST, PSYCHIATRIST OR

COUNSELOR?

c YES

c NO

IF YES, GIVE NAMES AND REASONS FOR VISITS:

 

 

 

 

B. CHILDREN OF PRIOR MARRIAGE

DO YOU HAVE ANY CHILDREN BORN OF A PRIOR MARRIAGE?

c YES

c NO

Full Legal Name

Age and Date of Birth

Living With

 1.

 

 

 

 2.

 

 

 

 3.

 

 

 

 

DOES YOUR SPOUSE HAVE ANY CHILDREN BORN OF A PREVIOUS MARRIAGE?

c YES

c NO

Full Legal Name

Age and Date of Birth

Living With

 1.

 

 

 

 2.

 

 

 

 3.

 

 

 

 

IV. PROPERTY

PLEASE REVIEW THIS CHECKLIST OF POSSIBLE ASSETS AND CHECK IF YOU OWN ANY OF THE FOLLOWING:

Ł

SEPARATE REAL PROPERTY

Ł

BUSINESS OWNED BY SPOUSE

Ł

FEDERAL DISABILITY

Ł

OUT OF STATE REAL PROPERTY

Ł

MONEY LENT TO OTHERS

Ł

TEACHERS RETIREMENT

Ł

THE MARITAL HOME

Ł

ACCOUNTS RECEIVABLE

Ł

TRUSTS

Ł

CERTIFICATES OF DEPOSIT

Ł

SEVERANCE PAY

Ł

LITIGATED AWARDS

Ł

CONTENTS OF SAFE DEPOSIT BOX

Ł

PROFIT SHARING PLAN

Ł

ANNUITIES

Ł

MORTGAGES OWNED BY SPOUSE

Ł

MILITARY RETIREMENT

Ł

ENDOWMENTS

Ł

WORKMEN’S COMPENSATION

Ł

PENSION RIGHTS

Ł

ART OBJECTS

Ł

VALUE OF LAW/MED DEGREE

Ł

SPOUSE’S PENSION

Ł

MILITARY DISABILITY

Ł

PARTNERSHIP INTEREST

Ł

TERM LIFE INSURANCE

Ł

SEPARATE ASSETS

Ł

SPOUSES PROFESSIONAL PRACTICE

Ł

RAILROAD RETIREMENT

Ł

COLLECTIONS

 

A. REAL ESTATE

FAMILY HOME OWNED?

c YES

c NO

ADDRESS:

 

DATE HOME PURCHASED:

 

PRICE PAID:

 

DOWN PAYMENT:

 

WHO CONTRIBUTED TO DOWN PAYMENT:

 

WHAT WAS THE SOURCE OF FUNDS FOR DOWN PAYMENT?

 

IS THERE DOCUMENTATION OF DOWN PAYMENT FUNDS/PAYMENT THEREOF?

c YES

c NO

CURRENT FAIR MARKET VALUE:

 

BALANCE OWED ON MORTGAGE:

 

ATTACH COPY OF DEED OR DOCUMENT WITH COMPLETE LEGAL DESCRIPTION

OTHER REAL ESTATE OWNED?

c YES

c NO

LIST DETAILS, AS ABOVE:

 

 

 

B. PERSONAL PROPERTY
  • AUTOMOBILES

          Model

Year

License Number

Present Value

Amount Owed

 1.

 

 

 

 

 

 2.

 

 

 

 

 

 3.

 

 

 

 

 

 4.

 

 

 

 

 

 

  • BOATS AND TRAILERS

          Name of Manufacturer

Year

Registration Number

Present Value

Amount Owed

 1.

 

 

 

 

 

 2.

 

 

 

 

 

 

  • BANK ACCOUNTS

          Bank/Branch

Account Number

Current Balance

Signatories

Balance at Separation

 1.

 

 

 

 

 

 2.

 

 

 

 

 

 3.

 

 

 

 

 

 4.

 

 

 

 

 

 
  • LIFE INSURANCE

          Company

Policy Number

Face Amount

Person Insured

Amount of Outstanding Loans

 1.

 

 

 

 

 

 2.

 

 

 

 

 

 3.

 

 

 

 

 

 4.

 

 

 

 

 

 

  • MEDICAL INSURANCE

DO YOU HAVE MEDICAL INSURANCE COVERAGE THROUGH YOUR EMPLOYER?

c YES

c NO

IF YES, WHO IN THE FAMILY IS COVERED?

 

FULL OR PARTIAL COVERAGE? (Describe):

 

DESCRIBE SPOUSE’S MEDICAL AND DENTAL COVERAGE:

 

 

 

 

  • PENSION OR RETIREMENT BENEFITS

       Name of Employer

Which Spouse

Number of Years Employed

 1.

 

 

 

 2.

 

 

 

 3.

 

 

 

 4.

 

 

 

 

  • STOCKS AND BONDS

          Name of Company

Number of Shares

Current Price per Share

Total Value

 1.

 

 

 

 

 2.

 

 

 

 

 3.

 

 

 

 

 4.

 

 

 

 

 

  • CERTIFICATES OF DEPOSIT, T-BILLS OR OTHER INVESTMENTS

          Face Amount

Maturity Date

Where Located

Interest

 1.

 

 

 

 

 2.

 

 

 

 

 3.

 

 

 

 

DO YOU OR YOUR SPOUSE HAVE ANY LAWSUITS OR POTENTIAL LAWSUITS PENDING IN WHICH EITHER OF YOU

ARE (OR COULD BE) A PLAINTIFF OR DEFENDANT?

c YES

c NO

IF YES, EXPLAIN:

 

 

 

  • FAMILY BUSINESS IN WHICH YOU OR YOUR SPOUSE HAVE AN INTEREST

NAME OF BUSINESS:

 

DATE STARTED:

 

  c CORPORATION

c PARTNERSHIP

PROFIT OR LOSS LAST YEAR:

 

  NET WORTH OF BUSINESS:

 

BOOKEEPING METHOD:

 

NAME OF CPA FOR BUSINESS:

 

IF CORPORATION, DO YOU OR YOUR SPOUSE OWN SHARES OF STOCK?

c YES

c NO

ARE EITHER OF YOU AN OFFICER OR ON THE BOARD OF THE CORPORATION?

c YES

c NO

TITLE/POSITION:

 
  • OTHER FINANCIAL INFORMATION

HAVE EITHER OF YOU FILLED OUT FINANCIAL STATEMENTS FOR LOANS OR CREDIT CHECKS WITHIN THE LAST

FIVE (5) YEARS?

c YES

c NO

Date Made

For Whom

 1.

 

 

 2.

 

 

 3.

 

 

 4.

 

 

 5.

 

 

 

  • ANY ADDITIONAL MAJOR ASSETS OWNED BY YOU AND YOUR SPOUSE

               (Including but not limited to antiques, furniture, tools, art, sporting equipment, etc.)

          Article

To Whom Should It Be Awarded at Time of Dissolution

Present Value

Amount Owed

If Any

 1.

 

 

 

 

 2.

 

 

 

 

 3.

 

 

 

 

 4.

 

 

 

 

 5.

 

 

 

 

 6.

 

 

 

 

 7.

 

 

 

 

 8.

 

 

 

 

 9.

 

 

 

 

 10.

 

 

 

 

 11.

 

 

 

 

 12.

 

 

 

 

 13.

 

 

 

 

 14.

 

 

 

 

 15.

 

 

 

 

 16.

 

 

 

 

 17.

 

 

 

 

 18.

 

 

 

 

 19.

 

 

 

 

 20.

 

 

 

 

 

HAVE YOU AND YOUR SPOUSE SIGNED A COMMUNITY PROPERTY AGREEMENT?

c YES

c NO

DATE EXECUTED:

 

WHERE LOCATED:

 

NAME OF ATTORNEY:

 

HAVE YOU AND YOUR SPOUSE SIGNED A PRE- OR POST-MARITAL AGREEMENT?

c YES

c NO

DATE EXECUTED:

 

WHERE LOCATED:

 

NAME OF ATTORNEY:

 

WHEN YOU MARRIED, DID EITHER OF YOU GIVE UP SOCIAL SECURITY, ALIMONY, RETIREMENT OR EMPLOMENT?

c YES

c NO

WHAT WAS GIVEN UP?

 

BY YOU OR SPOUSE:

 

AMOUNT RECEIVING AT TIME OF TERMINATION:

 

HOW MUCH LONGER WOULD IT HAVE BEEN RECEIVED?

 

CAN IT BE OBTAINED AGAIN?

 

 

 

DO EITHER OFYOU OWN SEPARATE PROPERTY (Separate property is property owned prior to marriage or received as a gift,

inheritance or acquired after separation)?

c YES

c NO

       Article

Present Value

Who Owns It

 1.

 

 

 

 2.

 

 

 

 3.

 

 

 

 4.

 

 

 

 5.

 

 

 

 

DO YOU HAVE A CPA?

c YES

c NO

NAME:

 

PHONE #:

 

ADDRESS:

 

 

 

V.  FINANCIAL DATA

A. INCOME

LIST ANNUAL GROSS INCOME FOR PAST TWO (2) YEARS (Provide copies of past two years IRS tax returns to attorney)

YEAR

WIFE

HUSBAND

 

 $

 $

 

 $

 $

 

PROJECTED INCOME FOR THIS YEAR:

     1. WAGES/SALARIES: (Provide two most recent pay stubs for you and your spouse)

WIFE

HUSBAND

 $

 $

     2. INTEREST & DIVIDEND INCOME:

 $

 $

     3. BUSINESS INCOME:

 $

 $

     4. SPOUSAL MAINTENANCE FROM OTHER RELATIONSHIPS:

 $

 $

     5. CHILD SUPPORT RECEIVED FROM OTHER RELATIONSHIPS:

 $

 $

     6. OTHER INCOME:

 $

 $

TOTAL PROJECTED GROSS INCOME THIS YEAR (Add rows 1 through 6)

 $

 $

 

B. ANNUAL REDUCTIONS IN INCOME FOR THIS YEAR

TAKE FIGURES FROM RECEIPT PAY STUBS AND MULTIPLY TO GET ANNUAL REDUCTIONS. FOR EXAMPLE, IF YOU

GET PAID WEEKLY, MULTIPLY FIGURE BY 52; IF YOU GET PAID TWICE PER MONTH, MULTIPLY FIGURE BY 24; IF

YOU GET PAID EVERY OTHER WEEK, MULTIPLY FIGURE BY 26.

WIFE

HUSBAND

     1. ANNUAL FICA (SOCIAL SECURITY):

 $

 $

     2. ANNUAL INCOME TAX WITHHELD FROM SALARY:

 $

 $

     3. UNION/PROFESSIONAL DUES:

 $

 $

     4. HEALTH OR LIFE INSURANCE PREMIUMS PAID FOR CHILDREN ONLY:

 $

 $

     5. PENSION OR RETIREMENT WITHHOLDING:

 $

 $

     6. STATE INDUSTRIAL INSURANCE:

 $

 $

     7. SPOUSAL MAINTENANCE PAID:

 $

 $

     8. NORMAL BUSINESS EXPENSES

 $

 $

TOTAL ANNUAL REDUCTIONS THIS YEAR (Add rows 1 through 8)

 $

 $

 

C. NET INCOME

WIFE

HUSBAND

ANNUAL NET INCOME (SUBTRACT B 9 FROM A 4):

 $

 $

MONTHLY NET INCOME (DIVIDE ANNUAL NET INCOME BY 12):

 $

 $

 

VI. CLIENT’S MONTHLY EXPENSES

YOUR EXPENSES SHOUD BE CALCULATED FOR THE FUTURE, AFTER SEPARATION, TAKING INTO ACCOUNT

PRESENT CUSTODY OR NON-CUSTODY OF CHILDREN. ALL FIGURES ARE ESTIMATED MONTHLY EXPENSES.

EXPENSES SUCH AS CLOTHING OR CAR REPAIR SHOULD BE ESTIMATED FOR THE WHOLE YEAR, THEN DIVIDED BY

12. IF IN DOUBT, TRY YOUR BEST TO ESTIMATE A FIGURE, BUT DO NOT LEAVE BLANK SPACES UNLESS THEY

CLEARLY DO NOT APPLY.

 

A. HOUSING

CLIENT

RENT, FIRST MORTGAGE OR CONTRACT PAYMENTS:

 $

INSTALLMENT PAYMENTS FOR OTHER MORTGAGES OR ENCUMBRENCES:

 $

TAXES AND INSURANCE (IF NOT INCLUDED IN MONTHLY PAYMENTS):

 $

REPAIRS AND MAINTENANCE:

 $

PROFESSIONAL CLEANING/GARDENER:

 $

TOTAL HOUSING EXPENSE

 $

 

B. UTILITIES

CLIENT

HEAT (GAS & OIL):

 $

ELECTRICITY:

 $

WATER, SEWER, GARBAGE:

 $

TELEPHONE:

 $

CABLE TV:

 $

TOTAL UTILITIES EXPENSE

 $

 

C. FOOD AND SUPPLIES (FOR--------PERSONS)

CLIENT

FOOD/GROCERIES EXPENSE:

 $

MEALS EATEN OUT:

 $

SUPPLIES (PAPER, TOBACCO, PETS):

 $

OTHER:

 $

TOTAL FOOD AND SUPPLIES EXPENSE

 $

 

D. CHILDREN

CLIENT

BABYSITTER/DAYCARE:

 $

CLOTHING:

 $

TUITION (IF ANY):

 $

OTHER CHILD RELATED EXPENSES:

 $

TOTAL CHILDREN EXPENSE

 $

 

E. TRANSPORTATION

CLIENT

VEHICLE PAYMENTS OR LEASES:

 $

VEHICLE INSURANCE AND LICENSE:

 $

TUITION (IF ANY):

 $

OTHER CHILD RELATED EXPENSES:

 $

TOTAL TRANSPORTATION EXPENSE

 $

 

F. HEALTH CARE (OMIT IF FULLY COVERED)

CLIENT

INSURANCE (IF NOT DEDUCTED FROM INCOME IN PARAGRAPH V.B.4., ABOVE):

 $

UNINSURED DENTAL, ORHTODONTIC, MEDICAL, EYE CARE EXPENSES:

 $

TOTAL HEALTH CARE EXPENSE

 $

G. PERSONAL EXPENSES

CLIENT

CLOTHING:

 $

HAIR CARE/PERSONAL CARE EXPENSES:

 $

CLUBS AND RECREATION:

 $

EDUCATION:

 $

BOOKS, NEWSPAPERS, MAGAZINES, PHOTOS:

 $

GIFTS:

 $

OTHER:

 $

TOTAL PERSONAL EXPENSE

 $

 

H. MISCELLANEOUS

CLIENT

INSURANCE (IF NOT DEDUCTED FROM INCOME IN PARAGRAPH V.B.4., ABOVE)

 $

OTHER:

 $

TOTAL MISCELLANEOUS EXPENSE

 $

 

I. INSTALLMENT DEBTS INCLUDED ABOVE (i.e. MORTGAGE)

Creditor

Description of Debt

Balance

Last Payment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J. OTHER DEBTS AND MONTHLY EXPENSES NOT INCLUDED ABOVE (i.e. CREDIT CARDS)

Creditor

Description of debt

Balance

Date of last payment

Monthly payment amount

 

 

 $

 

 $

 

 

 $

 

 $

 

 

 $

 

 $

 

 

 $

 

 $

 

 

 $

 

 $

 

 

 $

 

 $

 

 

 $

 

 $

 

K. AVAILABLE ASSETS

CLIENT

CASH ON HAND

 $

ON DEPOSIT IN BANKS

 $

STOCKS, BONDS, CASH VALUE OF LIFE INSURANCE

 $

OTHER LIQUID ASSETS

 $

TOTAL AVAILABLE ASSETS

 $

 

L. IF ATTORNEYS FEES ARE SOUGHT BY EITHER PARTY

TEMPORARY ATTORNEYS’ FEES AND COSTS REQUESTED

 $

FEES AND COSTS PAID TO MY ATTORNEY(S) TO DATE

 $

SOURCE OF FUNDS: