Family Law Intake Form "*" indicates required fields Today's Date Month Day Year Check One Divorce Custody Paternity Post-Judgement Adoption Other Please explain DemographicsYOUR INFORMATIONFull Name* NAME OF DECEDENT Middle Last Date of Birth Month Day Year AgeSocial Security Number GenderMaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerMarital StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipForeign Country Citizenship / ID # Address STREET CITY STATE ZIP PhoneEmail Do you check often? Yes No Driver's License Number Race Hair Color Eye Color Height Weight Scars/Identifying Marks Alias/Other Names Used Level of EducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to Answer YOUR SPOUSE/SIGNIFICANT OTHER/EXFull Name First Middle Last Date Month Day Year AgeSocial Security Number GenderMaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerMarital StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipForeign Country Citizenship / ID # Address Street Address City State / Province / Region ZIP / Postal Code PhoneEmail Do they check often? Yes No Driver's License Number Race Hair Color Eye Color Height Weight Scars/Identifying Marks Alias/Other Names Used Level of EducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to AnswerOpposing Attorney (If Any) Record of Divorce InformationYour Birthplace Number of this Marriage12345678910Your Spouse's Birthplace Number of this Marriage12345678910Place of this MarriageCity, Village, or TownshipCountyStateDate of Marriage Month Day Year Date of Separation Month Day Year Bride's Maiden Name and/or Name Before Marriage Minor ChildrenUse + to add linesFirst, Middle, LastAgeDOBM/FSSN (Required) Add RemoveCurrent Address of the Minor Children Listed Above STREET CITY STATE ZIP CustodyNowPost JudgementVisitationNowPost JudgementPlaces children have resided over last 5 yearsAddressWith WhomName and Contact Information of anyone else interested in Custody of the ChildrenAny current cases involving yourself, your spouse or the minor children? Yes No If yes, please explainMedical Insurance InformationYOURSELF (Use + to add lines)ProviderPlan NumberMedical/Dental/OpticalChildren Covered? Add RemoveSPOUSE (Use + to add lines)ProviderPlan NumberMedical/Dental/OpticalChildren Covered? Add RemoveEmploymentYOURSELFEmployer Name Address STREET CITY STATE ZIP PhoneJob Title Time at Job Gross Pay/WeekNet Pay/WeekHourly/ Avg # HrsGross Pay/YearSPOUSEEmployer Name Address STREET CITY STATE ZIP PhoneGross Pay/WeekNet Pay/WeekHourly/ Avg # HrsGross Pay/YearOther Sources of Income: (Unemployment, Pension, Retirement)Is either party receiving any sort of state aid? Yes No If yes, please state what is being received Child SupportTemporary Order Final Order (Click + to add more)No. DependentsAmount per ScheduleAgreed Amount Add RemoveAmount Case Number Marital PropertyREAL PROPERTY (Use + to add more)AddressValueAmount OwedPaymentRental?Name(s) on Deed Add RemoveVEHICLES (Use + to add more)Year/Make/ModelValueAmount OwedPaymentName(s) on Deed Add RemoveBANK ACCOUNTS (Use + to add more)Name of BankType of AccountJoint/IndividualBalance Add RemovePENSION/RETIREMENT ACCOUNTS (Use + to add more)Type of AccountWhose Account is this? Add RemoveDebts of Parties(Use + to add more)DescriptionAmountMonthly PaymentName on Debt Add RemoveAreas of DisputeCheck all that apply Property Division Child Custody Child Support Visitation Retirement Disability Debt Division Spousal Support NotesName First Last Address STREET COUNTY CITY STATE ZIP Home PhoneCell PhoneWork PhoneEmail How Did You Hear About Us?PLEASE SELECT ONEALLEGAN COUNTY LEGAL ASSISITANCE CENTERFACEBOOKALLEGAN NEWSONLINE SEARCHREFERRED BYOTHERPlease Explain Type of CasePLEASE SELECT ONECRIMINALFAMILY LAWWILLS/TRUSTSLITIGATIONBANKRUPTCYSOCIAL SECURITYOTHERPlease Explain CAPTCHANumberCommentsThis field is for validation purposes and should be left unchanged.
