(PLEASE COMPLETE FORM AND MAKE AN APPOINTMENT)
CHILD SUPPORT/CUSTODY DATA FORM
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 domestic situation.
We will also need a number of documents from you to complete your
matter. Please see the list on Page 6. 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 7
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): ______________________________
Date of birth: __________________________________________________________________
Length of Minnesota Residency: __________________________________________________
INFORMATION ABOUT CHILD(REN)’S FATHER/MOTHER (IF KNOWN)
Name: ________________________________________________________ Age: __________
(First)
(Middle)
(Last)
Address: ______________________________________________________________________
County ______________________________________________________________________
Telephone: ________________ home
________________ work __________________other
All other names previously known by (including maiden): ______________________________
Date of birth: __________________________________________________________________
Length of Minnesota Residency: __________________________________________________
FORMER RELATIONSHIP INFORMATION
How long were you involved with the father/mother of the child(ren)? ____________________
When did the relationship end? ___________________________________________________
Was child support ordered to be paid to either party? __________________________________
Who was it to be paid to? ________________________________________________________
Smith, Paulson, O’Donnell & Erickson, PLC
April 2015
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What is the amount of child support? _______________________________________________
When did it begin? _____________________________________________________________
Are there any arrearages and if so, how much? _______________________________________
What is the nature of the present problem? __________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do you or the other parent have any medical/mental health issues that impair your ability to earn
a living or necessitate major monthly medical expenses? Y N
If so, what is the condition and where are you or the other party treated? ___________________
_____________________________________________________________________________
_____________________________________________________________________________
INFORMATION ABOUT CHILDREN
Full Name
DOB
Resides With
SSN
Of this Relationship?
Is parentage in question? Explain: __________________________________________________
Do any of the children have disabilities? If so, explain: _________________________________
Is custody of the minor child(ren) contested? Y
N
What is the current parental access arrangement? ______________________________________
______________________________________________________________________________
______________________________________________________________________________
Smith, Paulson, O’Donnell & Erickson, PLC
April 2015
Page 3 of 7
Have you received/paid any support for the minor children? Y
N
If so, please indicate how much: ___________________________________________________
Is there an Order for child support in place? Y
N
If the issue concerns child support payments, complete the sections below regarding income
and expenses.
EMPLOYMENT
Name of Employer
Address of Employer
Job Title
Length of Employment
Income (Gross)
FATHER
MOTHER (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
FATHER
MOTHER (IF KNOWN)
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
MEDICAL/DENTAL INSURANCE
Do you have medical and/or dental insurance available to you and the child(ren) 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: $________________
Provided by other parent’s employer and/or union. Cost: $________________
Purchased privately. Cost $________ In whose name? ___________________
Smith, Paulson, O’Donnell & Erickson, PLC
April 2015
Page 4 of 7
REQUESTED DOCUMENTS:
1.
A COPY OF YOUR CURRENT PAYSTUBS, LISTING YEAR TO DATE
FIGURES.
2.
A COPY OF YOUR INCOME TAX RETURN, BOTH STATE AND FEDERAL,
FOR THE PAST YEAR.
3.
ANY COURT ORDERS RELATING TO CHILD SUPPORT/CUSTODY.
4.
HEALTH INSURANCE VERIFICATION.
5.
A LIST OF YOUR MONTHLY EXPENSES (SEE ATTACHED FORM).
Smith, Paulson, O’Donnell & Erickson, PLC
April 2015
Page 5 of 7
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
Smith, Paulson, O’Donnell & Erickson, PLC
April 2015
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Newspapers/Magazines
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
April 2015
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