1DIVORCE QUESTIONNAIRE

Plaintiff: _____________________________________
Defendant: ___________________________________
Date ______________________________
1.

CLIENT INFORMATION

Full Name: __________________________________________________________________

First
Middle
Maiden
Last
Address: ___________________________________________________________________
___________________________________________________________________________
City
State
Zip
County
How
Long?
SSN: __________________________

Drivers License #: ________________________

Home Phone: ___________________ Work: _________________ Other: _________________

E-Mail:
Date of Birth: ___________________________ State of Birth: __________________________
Number of this marriage for you: ____________

Race: _________________

Education: ________________________ Employed? Yes________ No ___________

Occupation: _______________________________ Salary: ____________________________
Employer: ____________________________________________________________________
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____________________________________________________________________
Hours Worked: __________________________________
2.
SPOUSES INFORMATION:
Full Name: ____________________________________________________________________
First
Middle
Maiden
Last
Address: _____________________________________________________________________
City
State
Zip
County
How Long?
SSN: ________________________________ Drivers License #: ____________________
Home Phone: ________________ Work: __________________ Other: ___________________
Date of Birth: ______________________ State of Birth: ________________________
Number of this marriage for you: ____________________________ Race: ________________
Education: _______________________________ Employed? Yes _______ No ___________
Occupation: ________________________________________ Salary: __________________
Employer: ____________________________________________________________________
_____________________________________________________________________________
Hours Worked: _______________________
Height: __________ Weight:_________ Eye Color: _____________ Hair Color: ____________
Scars/Tattoos: __________________________________________________________________
Auto Make/Model/Color: _________________________________________________________
Type Home: ______________________ Living With: ________________________________
3.

MARRIAGE INFORMATION:

Date of Marriage: ________________ County: ____________________ State: ______________

Date of Separation: ___________________________________
Address at Separation: __________________________________________ County: __________
4.

DIVORCE INFORMATION:

What happened at the time of the separation? _____________________________________

__________________________________________________________________________
__________________________________________________________________________
One Year Separation:
Have you had sex with your spouse since your separation? _______________
If yes, date(s)? _________________________________________________________________
Physical Abuse:
Was there abuse at the time of separation? __________________________________________
Were there bruises or marks? _____________________________________________
State what happened and when: ____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Witnesses to incident: ___________________________________________________________
_____________________________________________________________________________
Witnesses to bruises: ____________________________________________________________
______________________________________________________________________________
Describe any prior abuse: _________________________________________________________
______________________________________________________________________________
Witnesses: ____________________________________________________________________
______________________________________________________________________________
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Abuse/Harassment since separation? ________________________________________________

______________________________________________________________________________
When did it happen? _____________________________
Witnesses: ____________________________________________________________________
_____________________________________________________________________________
HABITUAL DRUNKENNESS/DRUG USE:
What does your spouse drink or use? ________________________________________________
How often does your spouse drink or use drugs? ______________________________________
How much does your spouse drink or use when they do? ________________________________
Witnesses to the drinking and drug use: _____________________________________________
_____________________________________________________________________________
Is your spouse still drinking or using drugs since the separation? __________________________
Witnesses to the drinking/drug use: _________________________________________________
Has your spouse ever been arrested for drunkenness or drug use? _________________________
If yes, give dates, locations, results: ________________________________________________
_____________________________________________________________________________
Has your spouse received treatment for drinking or drug use? ____________________________
If yes, give dates, locations, results: ________________________________________________
Witnesses: ____________________________________________________________________
Adultery:
Does your spouse have a girlfriend/boyfriend? Yes ______ No _____
Does your spouse live with the girlfriend/boyfriend? Yes _______ No _______
Does your spouse have children with the girlfriend/boyfriend? Yes ____ No ______

Does your spouse have a sexually transmitted disease? Yes _____ No ______
Describe any incidents, locations, and dates of your spouses adultery: ___________________
____________________________________________________________________________
Witnesses: ___________________________________________________________________
______________________________________________________________________________
5.

CHILDREN OF THE MARRIAGE (Include adopted children)

Name
Date/Place of
Birth
Current Address

Is wife Pregnant? Yes _____ No ______ Delivery Date: _______________________________

Is husband the biological father? Yes _______ No __________ Unsure __________
List every address where the children have lived for the past five years with the names and
addresses of the person with whom the children lived:
Counties of residents for
Persons with
whom
children
Dates
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Past 5 years
lived
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list below any children living with you who are not your spouses children:
Check here if none _________
Name
Date of Birth
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list below any children living with your spouse who are not your children:
Check here if none: __________
Name
Date of Birth
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6.

CHILD CUSTODY

Is there an Order of custody? Yes __________ No _______ If yes, date: ___________________

Who has physical custody of your children and for how long? ___________________________
_____________________________________________________________________________
Have there been any court cases concerning the custody of your children in this or any state?
Yes _______ No ______ If yes, give details: ________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
Do you know of any custody cases concerning your children now pending in this state or any
other state? Yes ____ No ______ If yes, give details: _________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you know of any person who has physical custody of the children or claims to have custody
or visitation rights with the children? Yes _____ No _____ If yes, who? ___________________
Do you want custody? Yes ____ No _______
Have you or another party been reported to DSS? Yes _______ No ______
If yes, who? ____________________________ When? _______________________________
Briefly describe what happened: ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
7.

VISITATION

If you do not have custody, what visitation would you like? ______________________________
______________________________________________________________________________
If you do have custody, what visitation are you willing to agree to? ________________________
______________________________________________________________________________
8.

SUPPORT

Is there an Order for support Yes _______ No _______ If yes, date: _______________________
Amount per month: $_______________
How is it paid: Directly to you ____ Through the Court ______ Wage Withholding ________

Do you want this support order to remain as it is? Yes _____ No ________
Are the payments current? Yes _____ No ________
If there is no support order, do you want child support? Yes _____ No _______
Are you or opposing party receiving TANF ( formerly AFDC) Yes _____ No _______
Do you or your spouse have health insurance for the children? Yes ____ No _______
Who pays for the insurance? Wife _____ Husband ______
How much is paid for the childrens part of the insurance alone? _________________________
Do you pay child support for any other children? Yes _____ No _______
If yes, how much? ___________ Is it court ordered? Yes ______ No _________
Does your spouse pay child support for any other children? Yes ____ No _______
If yes, how much? _____________ Is it court ordered? Yes ______ No _______
9.

MARITAL HOME

Do you and your spouse own a home? Yes _______ No ______

Is it a mobile home or a brick and mortar home? ____________________________________
Who is living in the marital home? ____________________________________________
If your spouse is living in the marital home, do you want it? Yes ______ No _______
If yes, can you afford the payments? Yes____ No ______
10.

ALIMONY

Do you want alimony? Yes ___ No _____

If yes, how long have you been married? _________________________________
Do you want your spouse barred from receiving alimony? Yes _______ No ________
11.

ADULTERY

Will your spouse accuse you of adultery? Yes ______ No ______

Can your spouse prove adultery? Yes ____ No ________

12.

CHILD CARE

Who pays for child care for the children? ______________________________

How much is paid for child care? $___________________
13.

PROTECTIVE ORDER

Do you have an Order of Protection? Yes _______ No ______ Date: ____________________

Do you want it to continue? Yes ______ No _______
If no, do you want one? Yes _____ No________
State your reasons why: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
14.

MAIDEN NAME

If you are the wife, do you wish to resume use of your maiden name? Yes _____ No ________
OR- do you prefer to resume use of your prior married name: Yes _______ No _______
If yes, what is your prior married name? ___________________________________________

15.

PROPERTY AND DEBTS

Automobiles You Own

Name on Title

Debt
owed
Balance

Payment
Make and Model
when bought
to whom
Due
Amount
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
Boats You Own

Name on
Title
Debt
Owed
Balance
Payment
When
Bought

Make and Model

to
Whom
Due
Amount
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Real Estate You Own

Name on Title

Debt Owed
Balance

(Land & Home)

When Bought

To Whom

Due

Payment
Due

______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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