(PLEASE COMPLETE FORM AND MAKE AN APPOINTMENT)
MARITAL DISSOLUTION DATA FORM
(WITH CHILDREN)
Smith, Paulson, O’Donnell & Erickson, PLC
201 West 7th Street
Monticello, MN 55362
(763) 295-2107
(763) 295-5165 Fax
It is important that you fill out this questionnaire as completely as
possible. Your attorney will be in a better position to answer questions
you may have concerning your marriage and domestic situation.
We will also need a number of documents from you to complete your
matter. Please see the list on Page 8. These documents should
accompany this questionnaire when it is returned to our office or as soon
as you can get them to us.
Thank you for choosing Smith, Paulson, O’Donnell & Erickson!
Patrick M. O’Donnell, Jacob T. Erickson, Carly West Holler
Michael J. Patera, Gregory V. Smith, Gerald S. Paulson
Date of Interview: ___________________________________________
Referred by: _______________________________________________
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 1 of 10
INFORMATION ABOUT YOURSELF
Date:___________________
Name: ________________________________________________________ Age: __________
(First)
(Middle)
(Last)
Social Security Number: _________________________________________________________
Address: ______________________________________________________________________
County ______________________________________________________________________
Telephone: ________________ home
________________ work __________________other
Is it o.k. to leave a message at these numbers? ________________________________________
All other names previously known by (including maiden): ______________________________
Will you request a name change? _____ To what?_____________________________________
Date of birth: __________________________________________________________________
Length of Minnesota Residency: __________________________________________________
INFORMATION ABOUT YOUR SPOUSE (IF KNOWN)
Name: ________________________________________________________ Age: __________
(First)
(Middle)
(Last)
Social Security Number: _________________________________________________________
Address: ______________________________________________________________________
County ______________________________________________________________________
Telephone: ________________ home
________________ work __________________other
All other names previously known by (including maiden): ______________________________
Will he/she request a name change? _____ To what?___________________________________
Date of birth: __________________________________________________________________
Length of Minnesota Residency: __________________________________________________
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 2 of 10
INFORMATION ABOUT MARRIAGE
Present marriage information:
Present separation date:
Date Married: ___________________________________
State: _______ City: ______ County:________________
_____________________________________________________
Previous separation dates:
_____________________________________________________
Were you previously married? ____ When/where divorced______________________________
Are you receiving/paying any money for support of children or former spouse? ______________
Number of children/spouses: _______________
Amount paid per month:
_______________
Arrearages:
_______________
Was spouse previously married? _____ When/where divorced:___________________________
Is your spouse receiving/paying any money for support of children or former spouse?_________
Number of children/spouses: _______________
Amount paid per month:
_______________
Arrearages:
_______________
INFORMATION ABOUT CHILDREN
Full Name
DOB
Resides With
SSN
Of this Marriage?
Is the wife pregnant at this time?
Y
N
Due Date: ____________________
If yes, is parentage in question? Explain: ____________________________________________
Is custody of the minor child(ren) contested? Y
N
Have you and/or your spouse received any treatment for fertility issues? Y N
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 3 of 10
If you are separated, what is the current parental access arrangement? _____________________
______________________________________________________________________________
______________________________________________________________________________
If you are separated, have you received/paid any support for the minor children?
If so, please indicate how much: _________
Is there an Order for child support in place? Y
N
Y
N
RESIDENCE
Is parties’ residence owned or rented? ________ If residence is owned, fill in the following as
accurately as possible:
Homestead owned by: Husband
Wife
Joint Tenancy
Other________________________
Address of homestead ___________________________________________________________
Date Acquired:
Fair Market Value:
Net Value:
_________________
$________________
$________________
Purchase Price:
$___________
1st Mortgage Balance
$___________
Lender: ____________________________
Monthly Payment:
$___________
nd
2 Mortgage Balance:
$___________
Lender:_____________________________
Rental Income:
$___________
OTHER REAL PROPERTY
Other property owned by: Husband
Wife
Joint Tenancy
Other_____________________
Address of other property ________________________________________________________
Date Acquired:
Fair Market Value:
Net Value:
_________________
$________________
$________________
Purchase Price:
$___________
st
1 Mortgage Balance
$___________
Lender: ____________________________
Monthly Payment:
$___________
nd
2 Mortgage Balance:
$___________
Lender:_____________________________
Rental Income:
$___________
If any additional real estate is owned, provide the same information for other real property
owned individual by you, your spouse or jointly. (Use reverse side.)
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 4 of 10
EMPLOYMENT
Name of Employer
Address of Employer
Job Title
Length of Employment
Income (Gross)
HUSBAND
WIFE (IF KNOWN)
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
OTHER INCOME/EMPLOYMENT BENEFITS
Public Assistance (AFDC/GA)
Unemployment/Worker’s Comp.
Interest Income
Dividend Income
Social Security Benefits for
Party or Child(ren)
Bonus
Expense Reimbursement
Per Diem Compensation
Other
HUSBAND
WIFE (IF KNOWN)
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Do you or your spouse receive public assistance or state medical benefits? If so, what:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 5 of 10
ACCOUNTS
Financial Institution
Type of
Account
Account #
Balance
Name on
Account
STOCKS/BONDS, ETC. AND RETIREMENT ACCOUNTS
Financial Institution
Type of
Account
Account #
Balance
Name on
Account
SECURED AND UNSECURED DEBTS (Excluding homestead and motor vehicles.)
Creditor’s Name
Account
Number
Name on
Account (When
Debt Incurred)
Approximate
Balance Due
and Owing
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 6 of 10
Party
Responsible for
Payment of
Debt
MOTOR VEHICLES/BOATS/MOTORS/TRAILERS/CAMPERS/SNOWMOBILES,
ATV’S, ETC. (Use separate sheet if needed for additional vehicles)
Year/Make/Model FMV
Loan
Monthly
Payment
Possession
of:
VIN #
List any larger items of tools and/or yard equipment and provide the year/make/model and fair
market value (use reverse side if needed): ___________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
NON-MARITAL CLAIMS
Do you have any real or personal property that you believe belongs only to you? If so, state the
item and approximate value(s). ___________________________________________________
____________________________________________________________________________
MEDICAL/DENTAL INSURANCE
Do you have medical and/or dental insurance available to you either privately or through your
employer? Check any of the following that apply:
_______
_______
_______
_______
Health Insurance Only
Includes Dental and/or Vision
Provided by your employer and/or union.
Cost to you for individual coverage: $________________
Cost to you for family coverage:
$________________
Provided by spouse’s employer and/or union.
Employee cost for individual coverage:
$________________
Employee cost for family coverage:
$________________
Purchased privately. Cost $________ In whose name? ___________________
_______
Life Insurance.
_______
Cost $________
In whose name? ___________________
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 7 of 10
REQUESTED DOCUMENTS:
1.
A COPY OF YOUR DEED FOR ANY AND ALL REAL PROPERTY:
(MORTGAGE NOTE, QUIT CLAIM DEED OR CONTRACT FOR DEED)TO
ASSURE ACCURACY OF LEGAL DESCRIPTION.
2.
A COPY OF A RECENT APPRAISAL, IF ONE HAS BEEN COMPLETED, FOR
ANY AND ALL REAL PROPERTY.
3.
A COPY OF A CURRENT MORTGAGE STATEMENT(S).
4.
A COPY OF YOUR CURRENT PAYSTUBS, LISTING YEAR TO DATE
FIGURES.
5.
A COPY OF YOUR JOINT OR INDIVIDUAL INCOME TAX RETURN, BOTH
STATE AND FEDERAL FOR THE PAST YEAR.
6.
ANY DOCUMENTS REGARDING PENSION/RETIREMENT AND/OR PROFIT
SHARING PLANS.
7.
ANY COURT ORDERS RELATING TO CHILD SUPPORT/CUSTODY.
8.
HEALTH INSURANCE VERIFICATION.
9.
A COPY OF ALL LIFE INSURANCE POLICIES WITH A CASH VALUE.
10.
A LIST OF YOUR MONTHLY EXPENSES (SEE ATTACHED FORM).
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 8 of 10
ITEM
Mortgage Payment (P.I.T.I./Rent)
R.E. Taxes (If Not Included in Mortgage)
Renter's/Homeowner's Insurance (If Not Included in Mortgage)
2nd Mortgage/Home Equity Line of Credit
Association Fee
Electricity
Heat
Water
Refuse Disposal
Telephone
Cable TV
Cellular Phone
Home Maintenance and Repair
House Cleaning
Lawn Care
Snow Removal
Maintenance
Utilities
Food/Groceries
Lunches at Work/School
Eating Out
Household Supplies
Clothing
Dry Cleaning/Laundry
Medical Insurance
Uncovered Medical Expenses
Prescriptions
Eye Care
Therapy/Counseling
Dental Insurance
Uncovered Dental Costs/Orthodontia
Automobile Payment
Gas/Oil/Maintenance
Automobile Insurance
Parking
Life/Disability Insurance Premiums
Recreation/Entertainment/Vacation
Newspapers/Magazines
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 9 of 10
Dues/Clubs
Personal Items/Incidentals
Hair Care
Child Care/Daycare/Babysitter
School Tuition/Expenses/Books
Activity Fees/Sports
Allowances
Non-School Classes
Adult Education Expenses
Pet Expenses
Contributions/Religious Charity
Other Miscellaneous
Monthly Debt Reduction (Credit Card Payments)
TOTAL MONTHLY EXPENSES
TOTALLY MONTHLY NET INCOME (approx.)
SURPLUS/SHORTFALL
Smith, Paulson, O’Donnell & Erickson, PLC
August 2015
Page 10 of 10