General Information1. Client* Husband Wife 2. Who Referred You to Our Office?* 3. Name* 4. Birth Date* 5. Phone*6. Email* 7. 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County of Residence* 2. Have you resided in your home county AND the State of Oklahoma for at least 6 months?* Yes No Date of Marriage* 4. Location of Marriage* 5. Date of Separation* 6. If you have minor children, with whom have they lived since separation? Information Regarding Children1. Do you have children? If so, please include their full name(s), age, DOB, and if the child was born of this marriage or was adopted.2. Please list all addresses you, your spouse, and any minor children have lived for the past 5 years AND provide the dates in chronological order, beginning with the most recent.*3. Have either you or your spouse participated as a party, witness, or in any other capacity, in any type of litigation concerning the custody of your child(ren) in this state or any other state? Yes No If "Yes," please explain.4. Is there any type of custody proceeding concerning your child(ren) now pending in any Court of this State or any other State to your knowledge? Yes No If "Yes," please explain.5. Is there any other person or entity who has physical custody of your child(ren) OR claims some right to have custody or visitation privileges with respect to your child(ren)? Yes No If "Yes," please explain.6. Who do you propose be the custodial parent? Father Mother Joint If joint custody, what percentage of time will the children live with each parent?7. Please express your proposed Child visitation:Indian Descent1. Are you of Indian descent? Yes No 2. Is your spouse of Indian descent? Yes No 3. If "Yes" to either of the above questions, please give us the name of the Tribe. 4. Are you or your spouse properly enrolled on the Tribal Rolls? Yes No 5. Are the children currently enrolled on the Tribal Rolls to your knowledge? Yes No 6. Are the children eligible for membership in an Indian Tribe? Yes No Health Insurance Policy1. Do you maintain health insurance on your children? I Do Spouse Does 2. Is the health insurance provided through a private plan or through the employer? Provided by me Provided by spouse Provided through my employer Provided through spouse's employer 3. What is the total cost (premium) of the health insurance per month? 4. What is the cost (premium) of the health insurance FOR THE CHILDREN ONLY per month? 5. If the health insurance is provided by your employer or your spouse’s employer, does the employer pay the employee’s, i.e., your’s or your spouse’s health insurance premium? Yes No 6. How many individuals are covered by this health insurance policy? 7. Are there any individuals covered under this policy who are not children of this marriage? Yes No If "Yes," how many? 8. Do you, your spouse, or children receive any health insurance through DHS or other state agency? Yes No If "Yes," please explain: Child Care for Children1. If your children are in child care, what is the name of the Child Care Center? 2. Which children are in child care? 3. What is the weekly cost of the child care? 4. Who currently pays for the child care? Mother Father DHS 5. Does this amount take into consideration any “extras” (field trips, birthday parties, etc.) that the child care provider may charge? Yes No If "No," what is the average amount per month that the child care provider charges each month? Prior Marriage (If Applicable)1. Former Spouse's Name 2. Date of Divorce 3. City Where Divorce Was Granted 4. Is prior spouse living? Yes No If "No," please enter the date of death 5. Did you live with a member of the opposite sex prior to this marriage? Yes No 6. Did your spouse live with a member of the opposite sex prior to this marriage? Yes No 7. Is it possible that either of you were in a common law marriage as a result? Yes No If "Yes," please explain. Military History1. If you or your spouse served in the military, please provide details below.Family's Present Health (Good/Poor and an Explanation)1. Your Health2. Spouse's Health3. Children's HealthIncome Information1. Please attach copies of your State and Federal Income Tax Returns for the last three taxable years.Max. file size: 40 MB.2. Please attach wage statements from your employer for last four pay periods.Max. file size: 40 MB.3. What is the husband's total gross income? 4. What is the wife's total gross income? 5. What is the husband's total deduction amount? 6. What is the wife's total deduction amount? Net Monthly Income1. What is the husband's total income minus total deductions? 2. What is the wife's total income minus total deductions? Separate Property1. Please list all property which was acquired by either you or your spouse (1) prior to marriage, (2) by inheritance, or (3) since the date of separation. Additionally, please indicate the date it was acquired, where it was acquired, who currently possesses it, and its current value.Marital Assets1. Please list any automobiles you own and include the following: 1) Year/Make, 2) VIN, 3) How title is held, 4) Current retail value, 5) Amount owed, and 6) Monthly payment2. Please list any stocks or bonds you own, including: 1) Name of company, 2) Policy #, 3) Face amount, and 4) Cash value accumulated3. Please list any cash and deposit accounts in your name, including: 1) Bank/Credit union name, 2) Account #, 3) Type of account, 4) Balance on date of separation, and 5) Balance on date of petition4. Please list any life insurance policies in your name, including: 1) Name of company, 2) Owner & beneficiary, 3) Face amount, and 4) Cash value accumulated5. Please list any 401(k) or Retirement accounts in your name, including: 1) Name of account, 2) Owner, 3) Balance on date of marriage, and 4) balance on date of petition6. Real Estate: Where more than one parcel of real estate owned, attach sheet with the following identical information for all additional property: 1) Legal Description (Attach copy of Deed), 2) Street Address, 3) Type of Property, 4) Date of Acquisition, 5) Original Cost, 6) Cost of Additions, 7) Total Cost, 8) Total Present Value (Attach most recent appraisal), 9) Mortgage Balance, 10) Other Liens, 11) Equity, 12) Monthly Mortgage Payment, 13) Mortgage Holder, 14) Taxes, and 15) Individual ContributionsMax. file size: 40 MB.7. Please list any business interests you have, including: 1) Name of business, 2) Share, 3) Type of business, 4) Current value, 5) Debt8. Please list any other relevant assets you own, including: 1) Name of asset, 2) Date acquired, 3) Source of Acquisition, 4) Current possession, 5) Current valueSeparate Debts1. Please list all debts which were acquired by either you or your spouse prior to marriage (or since the date of separation), including: 1) Creditor's name, 2) Who/what the debt is for, 3) Date acquired, 4) Balance, and 5) Monthly paymentBudget1. Number of people living in your household 2. What is each person's relationship to you?3. Which party is the custodial parent? 4. Who pays the rent or mortgage? Husband Wife 5. Who pays the real property taxes? Husband Wife 6. Who pays the real property insurance? Husband Wife 7. Who pays for residential maintenance? Husband Wife 8. Who pays for food and household supplies? Husband Wife 9. Who pays for utilities (water, electricity, gas/heat, etc)? Husband Wife 10. Who pays for phone service? Husband Wife 11. Who pays for laundry and cleaning supplies? Husband Wife 12. Who pays for clothing? Husband Wife 13. Who pays for uninsured medical expenses? Husband Wife 14. Who pays for uninsured dental expenses? Husband Wife 15. Who pays for insurance (life, health, accident, comprehensive, liability, and disability)? Husband Wife 16. Who pays for child care? Husband Wife 17. Who pays for child/spousal support from a prior marriage? Husband Wife 18. Who pays for school expenses? Husband Wife 19. Who pays entertainment expenses? Husband Wife 20. Who pays incidental expenses (grooming, tobacco, alcohol, gifts, etc)? Husband Wife 21. Who pays for transportation (other than automobile)? Husband Wife 22. Who pays for automobile expenses (gas, oil, repair, insurance, etc)? Husband Wife 23. Who makes automobile payments? Husband Wife 24. If you are making installment payments, please list each total and attach an itemized schedule:Max. file size: 40 MB.25. If you have other expenses, please list each total and attach an itemized schedule:Max. file size: 40 MB.26. To the best of your knowledge, please provide the total dollar amount of the HUSBAND'S budget expenses. 27. To the best of your knowledge, please provide the total dollar amount of the WIFE'S budget expenses. Temporary Support1. Since the date of your separation, have you received OR paid any child support to your spouse? Yes No If "Yes," please list how much you have received/paid and the dates of the payments.2. Since the date of your separation, have you received OR paid any alimony to your spouse? Yes No If "Yes," please list how much you have received/paid and the dates of the payments.If you answered "No" to either of the above questions, please explain why no support has been paid.Contested Issues1. Will your spouse contest this divorce action as to THE CUSTODY OF THE CHILDREN? Yes No If "Yes," please state the reason(s):2. Will your spouse contest this divorce action as to THE DIVISION OF PROPERTY? Yes No If "Yes," please state the reason(s):3. Will your spouse execute a WAIVER to avoid cost of service of summons? Yes No If "No," where is the best place to have him/her served with the Divorce Petition (address)?4. Have you or your spouse ever filed for Divorce from the other? Yes No If "No," in what State and County was the action filed and what was the date of filing?Wife's Former Name1. WIFE ONLY: At the time of the final Decree, do you wish to be restored to a former name? Yes No Former Name AuthorizationPlease check the box below and click "Submit" to send your intake form to our office.* I have read the above and foregoing document and have provided the information as requested. The information is true and correct to the best of my knowledge and belief. Δ
