The Law Office of C. Darlene Johnson
Attorney & Counselor at Law
257 Combs Road, Suite 1, Hazard, Kentucky 41701
cdjesq2016@gmail.com
DIVORCE INTAKE FORM
PETITIONER (About you):
Who referred you to this office? ___________________________________________________
1. Please give your full name, date and place of birth, and Social Security number.
Full Legal Name: _______________________________________________________________
Maiden Name: _________________________________________________________________
Birth Date: ________________________ City/State where born: _________________________
Driver’s License No.: ________________ Social Security No.: __________________________
2. Where are you living now, and what is your phone number?
Address: ______________________________________________________________________
City: ____________________ County: _____________________ State: ___________________
Zip: ____________________ Length of time in this County: ____________________________
Home Phone: _______________________ Work Phone: _______________________________
Cellular Phone: _____________________ Pager: _____________________________________
Fax Number: _______________________ Other: _____________________________________
3. E-Mail address: ______________________________________________________________
4. Mailing address: _____________________________________________________________
5. Preferred method communication (Email/Phone/Mail)? ______________________________
6. Have you consulted or retained any other attorneys on this matter before coming to this office?
______________________________________________________________________________
If so, please state which attorney and when: __________________________________________
7. Please complete the following information concerning your employment.
Employer: _________________________ Job Title: ___________________________________
Street Address: _________________________________________________________________
City, State, and Zip: _____________________________________________________________
Telephone No.: ___________________________ May we call you at work? ________________
Gross salary per month or annually: ________________________________________________
Length of Employment: __________________________________________________________
Highest Education Completed: ____________________________________________________
RESPONDENT (About your spouse or ex-spouse):
8. Please give your spouse’s or ex-spouse’s full name, date, and place of birth, and Social.
Full Legal Name: _______________________________________________________________
Maiden Name: _________________________________________________________________
Birth Date: ________________________ City/State where born: _________________________
Driver’s License No.: ________________ Social Security No.: __________________________
9. Where is your spouse or ex-spouse living now, and what is his/her phone number?
Address: ______________________________________________________________________
City: ____________________ County: _____________________ State: ___________________
Zip: ____________________ Length of time in this County: ____________________________
Home Phone: _______________________ Work Phone: _______________________________
Cellular Phone: _____________________ Pager: _____________________________________
Fax Number: _______________________ Other: _____________________________________
E-Mail address: ______________________________________________________________
Mailing address: _____________________________________________________________
Preferred method communication (Email/Phone/Mail)? ______________________________
Do you know if your spouse or ex-spouse has or will hire an attorney to represent them in this
matter? _______________________________________________________________________
If so, please state which attorney and when: __________________________________________
10. Please complete the following information concerning your spouse’s or ex-spouse’s
employment.
Employer: _________________________ Job Title: ___________________________________
Street Address: _________________________________________________________________
City, State, and Zip: _____________________________________________________________
Telephone No.: ___________________________ May we call him/her at work? _____________
Gross salary per month or annually: ________________________________________________
Length of Employment: __________________________________________________________
Highest Education Completed: ____________________________________________________
CHILDREN OF MARRIAGE:
11. Please give the full legal name, date and place of birth, sex, and Social of each child of this
marriage.
Name: _______________________________________________________________________
Sex (M/F): _______________ Date of Birth: ____________________ Age: ________________
Place of Birth: ________________________ Social: ___________________________________
Name: _______________________________________________________________________
Sex (M/F): _______________ Date of Birth: ____________________ Age: ________________
Place of Birth: ________________________ Social: ___________________________________
Name: _______________________________________________________________________
Sex (M/F): _______________ Date of Birth: ____________________ Age: ________________
Place of Birth: ________________________ Social: ___________________________________
Name: _______________________________________________________________________
Sex (M/F): _______________ Date of Birth: ____________________ Age: ________________
Place of Birth: ________________________ Social: ___________________________________
12. Will there be a dispute over the children? _________________________________________
If not, with whom will custody be? _________________________________________________
13. Where and with whom are the children living now?
______________________________________________________________________________
______________________________________________________________________________
ABOUT YOUR MARRIAGE AND SEPARATION:
14. Please give the date and place of your marriage:
Date: _______________________________________________________________________
Place: _______________________________________________________________________
Are you now legally separated from your spouse? ____________________________________
If so, please state the date of the separation: _________________________________________
MARITAL PROPERTY AND DEBT
15. Please indicate whether you have property jointly owned with your spouse or ex-spouse: Y/N
REAL PROPERTY: ____________________________________________________________
AUTOMOBILES: ______________________________________________________________
CHECKING/SAVINGS ACCOUNTS: ______________________________________________
RETIREMENT ACCOUNTS/ STOCKS/ BONDS/ MUTUAL FUNDS:
______________________________________________________________________________
______________________________________________________________________________
CHANGE OF NAME:
16. Please indicate whether you want to change your name/be restored your maiden’s name: Y/N
MAIDEN NAME: _____________________________________________________________
SERVICE OF CITATION:
17. WAIVER OF SERVICE: ____________________YES __________________________NO
18. Address for service on respondent: _____________________________________________
ADDITIONAL INFORMATION:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
AFFIDAVIT OF TRUTHFULNESS OF INFORMATION PROVIDED TO ATTORNEY
I, ____________________________, affirm that all of the information that I have provided on
this form is true and correct. I am aware that the information provided on this form will be used
to file a petition in a Court of Law and I understand that it is a criminal offense to provide false
information which the person knew or had reason to know will be used in any kind of filing with
the court of law and I take full responsibility for the truthfulness of the information provided on
this form.
__________________________
_______________________________
Signature of Client
Print Full Name
NOTICE TO CLIENT
I, ____________________________, understand that by completing this divorce questionnaire
does not in itself establish an attorney-client relationship. You must enter into a signed contract
with the attorney in order to establish an attorney-client relationship.
SIGNATURE: _________________________ DATE: ________________________________
REMARKS:
______________________________________________________________________________
______________________________________________________________________________
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