Jaspers, Moriarty, Walburg, Probate, Estate Planning, Real Estate, Business, Commercial, Personal Injury, Family, Divorce, Criminal, DWI, Litigation, Law Lawyer Attorney

206 Scott Street, Shakopee, MN 55379, Phone: (952) 445-2817, Fax: (952) 445-0812, Email:
kwetherille@jmwlaw.com

Jaspers, Moriarty & Walburg, P.A.

Client Information Questionnaire

Marriage Dissolution

So that we will be able to answer your questions and handle your case in a prompt and efficient manner, it is important that you attempt to answer the following questions fully and accurately. If you need additional space for an answer, you may use the back of a page. The completed questionnaire will be kept confidential and will remain in our possession. Please print.

Date:

Referred by:

YOUR CURRENT PERSONAL INFORMATION:

1. Full Name
Email Address:

2. All previous names you have ever used

3. Present Street Address
City
County
State
Zip

4. ADDRESS FOR MAIL IF DIFFERENT THAN HOME ADDRESS

5. Home Phone		Business Phone
Pager		Cellular Phone

6. Social Security Number
7. Length of Residence in Minnesota

8. Birthplace

Birthdate

Age

9. Present Health

10. Are you presently in the military service? Yes No

11. Name of person [other than your spouse] who would be most likely to always
know where you can be reached

Telephone Number Relationship to you

YOUR EMPLOYMENT INFORMATION:

1. Employer
2. Address
3. Occupation
4. Length of Time with this Employer

5. How often are you regularly paid:
Weekly Every two weeks Twice per month Monthly

7. Net Earnings

6. Gross Earnings		Per
	Per

8. Exemptions Claimed:	Federal		State

9. Deductions from you paycheck:

Federal		Per
State		Per
FICA		Per
Medical/Dental		Per
Other [Specify]		Per

10. Describe the type and amount of other income [overtime, bonuses, commissions, other employment]

11. Describe all other employment benefits [car, car allowance, meals, membership, etc.]

12. Do you receive, or expect to receive, any of the following as income:

Public Assistance	Yes	No
Social Security Benefits for Yourself	Yes	No
Social Security Benefits for Child[ren]	Yes	No
Unemployment Compensation	Yes	No
Worker's Compensation	Yes	No
Rental Income	Yes	No
Other Income	Yes	No

If yes, What:

SPOUSE'S PERSONAL INFORMATION:

1. Full Name

2. All previous names your spouse has ever used

3. Present Street Address
City
County
State
Zip

4.Home Phone

Business Phone

5.Social Security Number
6. Length of Residence in Minnesota
7. Birthplace	Birthdate	Age

8. Present Health

9. Is your spouse presently in the military service? Yes No

10. ADDRESS FOR MAIL IF DIFFERENT THAN HOME ADDRESS

SPOUSE'S EMPLOYMENT INFORMATION:

1. Employer
2. Address
3. Occupation
4. Length of Time with this Employer

5. How often is spouse regularly paid:
Weekly Every two weeks Twice per month Monthly

6. Gross Earnings		Per
7. Net Earnings		Per

8. Exemptions Claimed:	Federal		State

9. Deductions from you paycheck:

Federal		Per
State		Per
FICA		Per
Medical/Dental		Per
Other [Specify]		Per

10. Describe the type and amount of your spouse's other income [overtime, bonuses, commissions, other employment]

11. Describe all other employment benefits of your spouse [car, car allowance, meals, membership, etc.]

12. Detail your spouse's prior work experience [what, when and where]

13. Do you receive, or expect to receive, any of the following as income:

Public Assistance	Yes	No
Social Security Benefits for Yourself	Yes	No
Social Security Benefits for Child[ren]	Yes	No
Unemployment Compensation	Yes	No
Worker's Compensation	Yes	No
Rental Income	Yes	No
Other Income	Yes	No

If yes, What:

CHILDREN BORN OR ADOPTED INTO THIS MARRIAGE:
[Do not list children from previous marriages or other relationships]:

1. Children:

Full Name	Age	Birthdate	Social Security #

2. Do the children now live with Client? Spouse Both

3. Do you want custody of this child/these children? Yes No

4. Do you expect a contest over who should have custody of the children? Yes No
Why?

MARITAL INFORMATION:

1. Did you sign a pre-marital [antenuptial] agreement? Yes No

2. Date of present marriage

3. City, county, and state where you were married

4. Are you and your spouse living together? Yes No

5. If not, date of separation

6. Are you, or your spouse, pregnant? Yes No

7. Is there a history of domestic abuse in your marriage relationship? Yes No

Describe

8. Have you or your spouse ever sought an order for protection as a result of domestic abuse? Yes No

INFORMATION ABOUT YOUR OTHER MARRIAGES OR RELATIONSHIPS:

1. Were you previously married? Yes No

2. When were you divorced?

3. City, county and state of divorce

4. Minor children from your previous marriages or relationships: [Do not list children born or adopted into your current marriage]:

Full Name	Age	Birthdate	Social Security #

5. Who received custody?

6. If custody was awarded pursuant to a paternity decree, state the date of the paternity decree and the city, county, and state in which it was issued

7. Maintenance and child support payments received by you:

Maintenance		per		from
Child Support		per		from

Maintenance and child support payments paid by you:

Maintenance		per		from
Child Support		per		from

8. Assets awarded to you

INFORMATION ABOUT YOUR SPOUSE'S OTHER MARRIAGES OR RELATIONSHIPS:

1. Was your spouse previously married? Yes No

2. When was your spouse divorced?

3. City, county and state of divorce

4. Minor children by from your spouse's previous marriages or relationships: [Do not list minor children born or adopted into your current marriage]:

5. Who received custody?

6. If custody was awarded pursuant to a paternity decree, state the date of the paternity decree and the city, county, and state in which it was issue

7. Maintenance and child support payments received by your spouse:

Maintenance		per		from
Child Support		per		from

Maintenance and child support payments paid by your spouse:

Maintenance		per		from
Child Support		per		from

8. Assets awarded to your spouse

YOUR HEALTH INSURANCE:

Coverage provided for:
[Check all that apply]

	Name of Carrier	You	Spouse	Dependents
1. Medical
2. Dental
3. Optical
4. Other

SPOUSE'S HEALTH INSURANCE:

Coverage provided for:
[Check all that apply]

	Name of Carrier	You	Spouse	Dependents
5. Medical
6. Dental
7. Optical
8. Other

ASSETS:

A. Homestead

1. Address
City
County
State

2. Do you have a copy of a deed to this property? Yes No

3. Is this property Abstract of Torrens?   Yes   No
If Torrens, Certificate of Title No.
Where is the Certificate of Title?

4. When was this homestead purchased? Cost

5. Amount of down payment

6. Source of down payment

7. In whose name(s) is the title?

8. What is the present fair market value?

9. Present mortgage or contract for deed balance

10. Monthly payment

11. To whom are the payments made?

12. Does the payment include taxes? Yes No Insurance? Yes No

13. What are the yearly taxes? Yes No Insurance? Yes No

14. Are house payments delinquent? Yes No
How much?

15. In the box below, describe all improvements made to the property during the marriage.

B. Other Real Estate:

1. Address
City
County
State

2. Type

3. Do you have a copy of a deed to this property? Yes No

4. Is this property Abstract or Torrens?   Yes   No
If Torrens, Certificate of Title No.
Where is the Certificate of Title?

5. When was it purchased? Cost

6. Amount of down payment

7. Source of down payment

8. In whose name(s) is the title?

9. Present fair market value

10. Present mortgage or contract for deed balance

11. Monthly payment

12. To whom are the payments made?

13. Does the payment include taxes? Yes No Insurance? Yes No

14. What are the yearly taxes? Yes No Insurance? Yes No

15. Are payments delinquent? Yes No Insurance? Yes No How much?

16. On the reverse side of this page, describe all improvements made to the property during the marriage.

C. Other Real Estate:

17. Address
City
County
State

18. Type

19. Do you have a copy of a deed to this property? Yes No Insurance? Yes No

20. Is this property Abstract or Torrens?   Yes   No Insurance?   Yes   No
If Torrens, Certificate of Title No.
Where is the Certificate of Title?

21. When was it purchased? Cost

22. Amount of down payment

23. Source of down payment

24. In whose name(s) is the title?

25. Present fair market value

26. Present mortgage or contract for deed balance

27. Monthly payment

28. To whom are the payments made?

29. Does the payment include taxes? Yes No Insurance? Yes No

30. What are the yearly taxes? Yes No Insurance? Yes No

31. Are payments delinquent? Yes No How much?

32. On the reverse side of this page, describe all improvements made to the property during the marriage.

WE WILL NEED A COPY OF A DEED OR MORTGAGE CONTAINING THE LEGAL DESCRIPTION FOR EACH PARCEL OF REAL ESTATE.

D. Savings Accounts:

1. Depository		Balance
Name(s) on Account

2. Depository		Balance
Name(s) on Account

E. Certificate of Deposit:

1. Depository		Balance
Name(s) on Account

2. Depository		Balance
Name(s) on Account

F. Checking Accounts:

1. Depository		Balance
Name(s) on Account

2. Depository		Balance
Name(s) on Account

G. Cash Management or Brokerage Accounts:

1. Depository		Balance
Name(s) on Account

2. Depository		Balance
Name(s) on Account

H. Stock:

1. Depository		Balance
Name(s) on Account

2. Depository		Balance
Name(s) on Account

I. Bonds:

1. Depository		Balance
Name(s) on Account

2. Depository		Balance
Name(s) on Account

J. Safe Deposit Box:

Depository
Describe contents
Who has access?

K. List all Pension/Retirement Plans [IRA, 401(k), Keogh, Profit Sharing, ESOP, SEP, PAYSOP, etc.]

	Type	In Whose Name?	Value
1.
2.
3.
4.

L. Does anyone owe you or your spouse money? Yes No Insurance? Yes No

1.	Who		How much
2.	Who		How much

M. Did you bring property or money into this marriage? Yes No Insurance? Yes No Describe

N. Did your spouse bring property or money into this marriage? Yes No Insurance? Yes No Describe

O. Describe any inheritance you have received

P. Describe any inheritance your spouse has received

Q. Do you have any personal injury or worker's compensation claim pending or have you received any settlement or award?

R. Do your spouse have any personal injury or worker's compensation claim pending or has your spouse received any settlement or award?

S. Life Insurance

1.	Company
2.	Type of Policy
3.	Name of Insured
4.	Name of Beneficiary
5.	Annual Premium	Face Value	Cash Value

1.	Company
2.	Type of Policy
3.	Name of Insured
4.	Name of Beneficiary
5.	Annual Premium	Face Value	Cash Value

1.	Company
2.	Type of Policy
3.	Name of Insured
4.	Name of Beneficiary
5.	Annual Premium	Face Value	Cash Value

T. Motor Vehicles Driven by YOU:

Kind

Year

Model

2. In whose name?
3. Balance owed  Payments  Per
4. Payments made to whom?

Motor Vehicles Driven by SPOUSE:

Kind

Year

Model

2. In whose name?
3. Balance owed  Payments  Per
4. Payments made to whom?

U. Recreational Vehicles:

	Make and Model	Value	Payments	Balance Due
Motorcycles
Snowmobiles
Boat, Motor & Trailer
Recreational Vehicles

V. Value of:

Jewelry		Furs		Art
Precious Metals		Collections [describe]

W. Household Goods and Furnishings:

1. Estimated value
2. Balance owed	Payments	Per
3. Payments made to whom?

X. Describe any other assets that you know of

DEBTS:

Creditors	Balance Due	Monthly Payment	Reason Debt Incurred	Person Incurring Debt
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

MISCELLANEOUS:

1. Do you or your spouse have a will? Yes No Insurance? Yes No

2. When were the wills executed or last revised?

3. Do you or your spouse desire to have a name change as a result of this proceeding? Yes No Insurance? Yes No
If so, what name is desired?

4. Are you or your spouse named as a party in any pending lawsuit, including bankruptcy? Yes No Insurance? Yes No

A COPY OF THE SUMMONS AND PETITION AND ANY OTHER COURT DOCUMENTS CONCERNING YOUR CASE, IF ANY, AS WELL AS LEGAL DESCRIPTIONS, TAX RETURNS, FINANCIAL STATEMENTS, AND OTHER FINANCIAL RECORDS SHOULD BE PROVIDED AS SOON AS POSSIBLE.

I understand that charges per hour for consultations, telephone conferences, and other time spent on my behalf. I agree to pay for these services.

Dated:

Signature