DISSOLUTION WORKSHEET W/ CHILDREN
(General Information)
[Please answer each question fully. If the question does not apply, please write “N/A” in the blank.]
CLIENT’S INFORMATION
NAME
1.
First, middle, last: ______________________________________
TELEPHONE
2.
Day phone:
3.
Residential phone:
4.
Cell/msg./pager phone:
5.
Fax number:
CURRENT RESIDENTIAL ADDRESS
6.
Residential street address:
7.
city:
8.
state:
9.
zip code:
, Inside City limits? Y __ N ___
MAILING ADDRESS (if different)
10.
Mailing street address or P.O. Box:
11.
City:
12.
State:
13.
Zip:
IDENTIFICATION/EMPLOYMENT
14.
SSN:
15.
Driver’s license number and state:
NEW CLIENT INFORMATION WORKSHEET
Page 1 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
16.
Employer name:
17.
Employer phone:
18.
Employer address:
VITAL STATISTICS
19.
Birth date:
20.
Other names (if any):
, State where born: ______________
SPOUSE’S INFORMATIOON
NAME
21.
Spouse’s name:
22.
Spouse’s maiden name:
TELEPHONE
23.
Spouse’s day phone:
24.
Spouse’s residential phone:
_____
CURRENT RESIDENTIAL ADDRESS
25.
Spouse’s residential address:
26.
City:
27.
State:
28.
Zip code:
, Inside city limits? Y__ N__
MAILING ADDRESS (if different)
29.
Spouse’s mailing address:
30.
City:
31.
State:
32.
Zip:
IDENTIFICATION/EMPLOYMENT
33.
Spouse’s SSN:
34.
Spouse’s driver’s license number (if known):
35.
Employer name:
NEW CLIENT INFORMATION WORKSHEET
Page 2 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
36.
Employer phone:
37.
Employer address:
VITAL STATISTICS
38.
Spouse’s birth date:
, State where born _________.
MARRIAGE
39.
Date of marriage:
40.
Where married:
41.
Date you separated from wife:
61.
Residence: Parties resided together in the State of Washington from:
to
62.
Residence of last five years (if different)
[city/state]
63.
Pregnancy: Is wife expecting a child? If so, when?
64.
Military Service: Is either party presently in the military service or retired from the
military service: If no skip to Children.
1.
2.
3.
4.
5.
Which party is/was in the military service:
Branch of service:
Rate or grade:
How long in service (years and months):
Current monthly pension payment received:
CHILDREN
NEW CLIENT INFORMATION WORKSHEET
Page 3 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
65.(A) Child #1
1.
Oldest child’s first name:
2.
Oldest child’s last name:
3.
Oldest child’s birth date:
4.
Oldest child’s birthplace:
5.
Oldest child’s SSN:
6.
Oldest child resides with (h/w/n):
7.
Is client oldest child’s mother? (y/n)
8.
Is spouse oldest child’s father? (y/n)
Age:
65.(B) Child #2
1.
Second child’s first name:
2.
Second child’s last name:
3.
Second child’s birth date:
4.
Second child’s birthplace:
5.
Second child’s SSN:
6.
Second child resides with (h/w/n):
7.
Is client second child’s mother? (y/n)
8.
Is spouse second child’s father? (y/n)
Age:
65.(C) Child #3
1.
Third child’s first name:
2.
Third child’s last name:
3.
Third child’s birth date:
4.
Third child’s birthplace:
5.
Third child’s SSN:
6.
Third child resides with (h/w/n):
7.
Is client third child’s mother? (y/n)
8.
Is spouse third child’s father? (y/n)
Age:
65.(D) Child #4
NEW CLIENT INFORMATION WORKSHEET
Page 4 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
1.
Fourth child’s first name:
2.
Fourth child’s last name:
3.
Fourth child’s birth date:
4.
Fourth child’s birthplace:
5.
Fourth child’s SSN:
6.
Fourth child resides with (h/w/n):
7.
Is client fourth child’s mother? (y/n)
8.
Is spouse fourth child’s father? (y/n)
Age:
66.
Names and present addresses of persons with whom children have lived during the
past five years if different then with you and wife:
67.
Current visitation with children, (how often each parent has children):
67a.
IDEAL visitation schedule with the children (custody and visitation)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
68.
OTHER LITIGATION: Has client participated as a party, witness or in any other
litigation concerning the custody of the children in this or any other state? If so, give details.
NEW CLIENT INFORMATION WORKSHEET
Page 5 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
69.
CUSTODY RIGHTS OF OUTSIDE PARTIES: Does client know of any person, not a
party to this proceeding who has physical custody of the children or claims to have custody
or visitation rights with respect to the children? If so, state details.
SCHEDULE INDEX
Only fill out the schedules for which you have information. If you don’t have the information then don’t worry
about it, we can get it later.
Schedule A – Family Home or other rental homes
Schedule B – Checking Accounts, Savings accounts, money market accounts
Schedule C – Personal Property (Cars, boats, etc.)
Schedule D – Stocks and Bonds
Schedule E – Money that people owe you
Schedule F – Business you and/or your husband own
Schedule G – Retirement Benefits, IRAs, 401(k), 403(b) you or your husband are entitled to
Schedule H – Other Items not listed elsewhere
Schedule I – Life insurance policies
Financial Declaration – THIS MUST BE FILLED OUT PRIOR TO OBTAINING TEMPORARY
ORDERS
NEW CLIENT INFORMATION WORKSHEET
Page 6 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE A
REAL PROPERTY
For each piece of real property, state on a separate page:
Location
Address
Owned in name of
Acquisition
Date acquired
How acquired
gift
inheritance
purchase
Purchase price
Cost of improvement
Means of purchase mortgage
deed of trust
contract
Fair market value
Value of equity
How do you want to divide this property?

Sell and split proceeds

Retain

Let my spouse have it
% by ___%
Appraisal:
Yes
No
$
Are taxes current:
Yes
No
Amount due $
NEW CLIENT INFORMATION WORKSHEET
Page 7 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE B
BANK ACCOUNTS
Name/Address
Of bank
Form of ownership
and with whom
Account
no.
Savings or
checking
Current
balance
Current
value
Face
amount
Do you own any certificates of deposit? If so, state:
Name/Address
Of bank
Form of ownership
and with whom
NEW CLIENT INFORMATION WORKSHEET
Page 8 of 21
Certificate
no.
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE C
PERSONAL EFFECTS
Automobiles
Year/make/model
Balance
Owing
Monthly
payment
Blue book
value
To husband
or wife
Blue book
value
To husband
or wife
Recreational vehicles
(boats, snowmobiles, motorbikes, trailers, campers, etc.)
Year/make/model
Balance
Owing
Monthly
payment
Jewelry, antiques, collections
Description
Value
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Page 9 of 21
To husband or wife
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE C – Continued
Personal Effects
Livestock
Description
Location
Current
Value
Amount
owing
To husband
or wife
Current
Value
Balance
owing
To husband
or wife
Furniture/furnishings
Description
Location
PLEASE SPECIFY “S” IF ANY OF THE ABOVE IS YOUR SEPARATE PROPERTY (ACQUIRED PRIOR TO MARRIAGE OR BY INHERITANCE)
NEW CLIENT INFORMATION WORKSHEET
Page 10 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE D
Stocks and Bonds
Bonds and Treasure Notes
Company and
Type
#of shares
Date
Acquired
Original cost Current
per share
value
To husband
or wife
#of shares
Date
Acquired
Original cost Current
per share
value
To husband
or wife
Stocks
Company and
Type
With respect to the corporate stock you have listed above, please state:
(A)
Whether any of the stock is pledged r otherwise encumbered as security for obligation or
purposes and, if so, briefly describe the transaction identifying the parties thereto.
(B)
The name and address of your broker or brokers.
ANSWER:
NEW CLIENT INFORMATION WORKSHEET
Page 11 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE E
Receivables
Person owing
You money
Current balance
Annual
Gross amount Interest rate Secured by Payment
CURRENT MORTGAGE(S)
Mortgagee/
Mortgagor
Gross
amount
Interest
rate
Length and
due date
Annual
payment
Current
balance
Interest
rate
Length and
due date
Annual
payment
Current
balance
CURRENT CONTRACT(S)
Mortgagee/
Mortgagor
Gross
amount
Additional comments/proposal for division:
SCHEDULE F
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Page 12 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
Business interest
Closely held business interest:
Name:
ownership interest:
Type of entity:
partnership
corporation
proprietorship
Fair market value of your interest:
Do you have a buy/sell redemption agreement?
If the business owns land, set forth:
(a) location and legal description (attach legal); (b) present
fair market value; (c) name and address of legal owner; (d) type of encumbrance, i.e. mortgage, deed
of trust, contract; (e) amount of lien; and (f) equity.
Other business assets/liabilities:
Description
Value
Depreciation
Net value
Equipment
Supplies
Inventory
Accounts receivable
Accounts payable
Other
NEW CLIENT INFORMATION WORKSHEET
Page 13 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE G
Retirement benefits
Retirement benefits through company or employee
COMPANY
TYPE OF PLAN
Also, please state the following:
1.
Name of program
2.
General description of the terms and benefits
3.
Name and address of the custodian of the fund
4.
Name and address of the person to be contacted regarding such fund or program
____________________________________________________________________
5.
Total amount of employer contributions to fund to date: $
6.
Present balance of your interest in the fund: $
7.
Date you are entitled to receive benefits upon early retirement and upon normal retirement
8.
Amount of benefits receivable per month on early retirement and upon normal retirement
$
NEW CLIENT INFORMATION WORKSHEET
Page 14 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE H
Other Assets
Description
Debt
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Page 15 of 21
Market Value
Who should get?
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
SCHEDULE I
Life Insurance
Company:
Policy No.:
Insured’s name:
Amount:
Type:
Annual premium:
Date issued:
Primary beneficiary:
Contingent beneficiary:
Cash value:
Loan amount:
NEW CLIENT INFORMATION WORKSHEET
Page 16 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
FINANCIAL DECLARATION
(Note: Please attach a current wage stub or statement and the last two years’ tax returns
filed.)
Employment information
Client:
Occupation:
Employer’s name/address:
Length of employment:
Beginning date of employment:
If you are not currently employed, please state your last employment date, gross monthly
earnings and reason for unemployment below.
Date:
Monthly earnings:
Reason for unemployment:
Highest year of education completed:
Spouse:
Occupation:
Employer’s name/address:
Length of employment:
If your spouse is not currently employed, please state their last employment date, gross monthly
earnings and reason for unemployment below.
Date:
Monthly earnings:
Reason for unemployment:
NEW CLIENT INFORMATION WORKSHEET
Page 17 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
Gross Monthly Income:
Wages and salaries:
Interest dividend income:
Spousal maintenance received from other relationships:
Other income:
Year to date gross income:
Business income (self-employment)
Self-employed business income:
Self-employed business expenses:
Monthly Deductions from Gross Income:
Income taxes:
FICA/self-employment taxes:
State industrial insurance:
Mandatory union/professional dues:
Pension plan payments:
Spousal maintenance paid:
Miscellaneous income:
Child support received from other relationships:
Name of paying parent:
Available assets:
Cash on hand:
On deposit in banks:
Stocks and bonds:
Cash value of life insurance:
Other:
NEW CLIENT INFORMATION WORKSHEET
Page 18 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
Monthly expenses:
Housing:
Rent, 1st mortgage or payments:
Installment payments for other mortgages/encumbrances:
Property taxes (if not in monthly payment): ($annual)
Insurance (if not in monthly payment): ($annual)
Association dues, if any ($annual)
Repairs $
Yard maintenance/upkeep $
Utilities:
Heat (gas and oil):
Electricity:
Water, sewer, garbage:
Telephone:
Cable:
Other:
Food and supplies:
Food for _____ person(s):
Supplies (paper, tobacco, pets):
Meals eaten out:
Children:
Day care/babysitting:
Clothing:
Tuition (if any):
Other child-related expenses:
NEW CLIENT INFORMATION WORKSHEET
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Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
Transportation:
Vehicle payments or leases:
Vehicle insurance and license:
Vehicle gas, oil, ordinary maintenance:
Parking:
Other transportation expenses:
Health care:
Health insurance:
Dental insurance:
Uninsured dental, orthodontic, medical, eye care expenses:
Other uninsured health care expenses:
Personal expenses (not including children):
Clothing:
Laundry/dry cleaning:
Hair care/personal care expenses:
Clubs and recreation:
Education:
Books, newspapers, magazines, photos:
Gifts:
Other:
Miscellaneous expenses:
Life insurance (if not deducted from income):
Church and other donations:
Other:
Other:
NEW CLIENT INFORMATION WORKSHEET
Page 20 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263
Other debts and monthly expenses, e.g. credit card debt, open accounts:
Creditor
Description
Month of
Amount of
last payment monthly payment
Balance
owing
Attorney’s fees and costs:
Attorney’s fees/costs paid to date:
Source of attorney’s fees/costs paid:
Arrangements made to pay attorney’s fees/costs:
NEW CLIENT INFORMATION WORKSHEET
Page 21 of 21
Arndt & Walker
Attorneys at Law, LLC
107 S. Main St. Suite B201
Coupeville, WA 98239
(360) 678-0259
Fax (360) 678-0263