The Narris Law Office
DIVORCE INTAKE FORM
CLIENT INFORMATION
Full legal name: __________________________________________________________
Current address: _________________________________
_________________________________
Maiden Name (if applicable):
________________________________
_________________________________
Current phone number: ____________________________
Cell phone number (if different): ______________________
Email: ____________________________________________
Social Security Number: ___________________
Date of birth:
___________________
Place of birth:
Number of prior marriages: _________
Date most recent marriage ended: ___________
SPOUSE INFORMATION
Is your spouse represented by an attorney?
If yes, please list the name, telephone number and address:
_____________________________________________
_____________________________________________
_____________________________________________
Full legal name: __________________________________________________________
Current address: _________________________________
_________________________________
_________________________________
Current phone number: ____________________________
Cell phone number (if different): ______________________
Maiden Name (if applicable):
________________________________
Email: ____________________________________________
Social Security Number: ___________________
Date of birth:
___________________
Place of birth:
Number of prior marriages: _________
Date most recent marriage ended: ___________
GENERAL INFORMATION:
Place of Marriage:
City ___________________________
County _______________________ State__________
Date of the Marriage ____________________________________
Date last lived together __________________________________
Did you live together before the marriage: Yes No
If so, for how long?
CHILDREN:
Please list your children’s full name, date of birth and Social Security Number
FULL NAME
DATE OF BIRTH
SSN
___________________________
_____________ ________
__________________
___________________________
_____________ ________
__________________
___________________________
_____________ ________
__________________
___________________________
_____________ ________
__________________
___________________________
_____________ ________
__________________
Does either spouse have other children? If so, please list their names and dates of birth:
If there are children outside of the marriage, please describe who has custody of those children and who pays support:
Please list any special issues involving the children’s medical, educational or emotional needs:

PLEASE BE SURE TO PROVIDE A COPY OF YOUR PAY STUB AS SOON AS YOU ARE ABLE AND
BE SURE TO HAVE RECENT COPIES FOR EACH COURT DATE TO ATTACH TO THE FINANCIAL
STATEMENT FILED WITH THE COURT
FINANCIAL INFORMATION:
Husband’s occupation:
Employer:
Monthly Gross Income (before taxes):
Monthly Net Income (after taxes):
Highest level of education:
Does Husband receive any overtime? If so, how frequent:
How long has Husband been employed in this profession?
Wife’s occupation:
Employer:
Monthly Gross Income (before taxes):
Monthly Net Income (after taxes):
Highest level of education:
Does Wife receive any overtime? If so, how frequent:
How long has Wife been employed in this profession?
Please describe any additional income received by you or your spouse:
Health issues of Husband:
Health issues of Wife:
HEALTH INSURANCE:
Is the health insurance provided through you or your spouse?
Are the children covered? Yes No
Policy holder: (Harvard Pilgrim, Blue Cross, etc.) ___________________________
Policy number: ___________________________________
How much money do you or your spouse contribute every month towards health insurance?
Are there any regular additional medical costs for the children beyond the health insurance coverage?
DAY CARE:
Are any of the children in day care? Yes
No
Provider:
Phone Number:
Annual cost of day care:
REAL ESTATE:
Do you and your spouse own a house together?
When was it purchased?
How did you put together the down payment? (was there a family gift or did you draw from a specific account?)
Purchase date: _________________________
Down payment: ________________________
Purchase price: ________________________
Amount owed:
Estimated fair market value: (Please be advised that a professional appraisal will likely be needed if either party wants
to remain in the home) ____________________________
Has either you or your husband purchased any real property since you have separated? If yes, please describe:
Have either you or your husband received any inheritance or valuable gifts since you began to live together or since
you married?
If so, please describe:
VEHICLES:
Husband’s:
Year
Make and Model
Used by
Value
Amt. Owed
Wife’s:
Year
Make and Model
Used by
Value
Amt. Owed
VALUABLES: Please list any collections, jewelry or other valuables owned by you or your husband:
Item
Estimated Value
_________________________________
____________________________________
Item
Estimated Value
_________________________________
____________________________________
Item
Estimated Value
_________________________________
____________________________________
Item
Estimated Value
_________________________________
____________________________________
DEBTS
Creditor
Acct#
Amount
____________________________
___________
Creditor
Amount
Acct#
____________________________
___________
Creditor
Amount
Acct#
____________________________
___________
Creditor
Amount
`Acct#
____________________________
Was this debt incurred during the marriage?
Was this debt incurred during the marriage?
Was this debt incurred during the marriage?
Was this debt incurred during the marriage?
___________
BANK ACCOUNTS
Bank/institution / Acct#: _______________________________________
Address:
Type of account: (checking, savings, money market, CD, mutual fund, etc.) ___________________________
Name on Account: ____________________________________________________________________
Current balance: _______________________
Bank/institution/ Acct#: _______________________________________
Address:
Type of account: (checking, savings, money market, CD, mutual fund, etc.) ___________________________
Name on Account: ____________________________________________________________________
Current balance: _______________________
Bank/institution/Acct#: _______________________________________
Address:
Type of account: (checking, savings, money market, CD, mutual fund, etc.) ___________________________
Name on Account: ____________________________________________________________________
Current balance: _______________________
Bank/institution/Acct#: _______________________________________
Address:
Type of account: (checking, savings, money market, CD, mutual fund, etc.) ___________________________
Name on Account: ____________________________________________________________________
Current balance: _______________________
STOCKS AND BONDS:
Name of Company:
______________________________________________________________
Number of Shares:
___________________
Name of Company:
______________________________________________________________
Number of Shares:
___________________
Name of Company:
______________________________________________________________
Value: ____________________
Value: ____________________
Number of Shares:
___________________
Value: ____________________
Name of Company:
______________________________________________________________
Number of Shares:
___________________
Value: ____________________
PENSIONS, STOCK PURCHASE PLANS AND OTHER INVESTMENT ACCOUNTS:
Type of Account:(SEP, Keogh, IRA, pension, etc.) ___________________________________
Name on the account (participant): ____________________________________________________
Name of Fund Administrator: _______________________________________________________
Address:
Account Number:
__________________________________
Balance:
__________________________________
Type of Account: (SEP, Keogh, IRA, pension, etc.) ____________________________________
Name on the account (participant): _____________________________________________________
Name of Fund Administrator: ________________________________________________________
Address:
Account Number:
__________________________________
Balance:
__________________________________
Type of Account: (SEP, Keogh, IRA, pension, etc.) ____________________________________
Name on the account (participant): _____________________________________________________
Name of Fund Administrator: ________________________________________________________
Address:
Account Number:
__________________________________
Balance:
__________________________________
Type of Account: (SEP, Keogh, IRA, pension, etc.) ____________________________________
Name on the account (participant): _____________________________________________________
Name of Fund Administrator: ________________________________________________________
Address:
Account Number:
__________________________________
Balance:
__________________________________
Type of Account: (SEP, Keogh, IRA, pension, etc.) ____________________________________
Name on the account (participant): _____________________________________________________
Name of Fund Administrator: ________________________________________________________
Address:
Account Number:
__________________________________
Balance:
__________________________________
LIFE INSURANCE POLICIES
Current life insurance policy on Husband:
Beneficiary:
Premium Amount:
Policy Amount:
Policy Type:
Company Name:
Policy Number:
Current life insurance policy on Wife:
Beneficiary:
Premium Amount:
Policy Amount:
Policy Type:
Company Name:
Policy Number:
Please list any other assets:
OTHER FAMILY ISSUES: (If any, to be discussed in more detail)
Was there ever any domestic violence in this relationship? YES
NO
Do you have any concerns about your spouse caring for your children? YES
NO