MAXWELL LAW FIRM, PLLC

NEW CLIENT INTAKE SHEET: DOMESTIC MATTER

http://www.maxwelllegal.com

Today’s Date: __________________

Full Name: ______________________________________Name called_________________

Home Address: _______________________City________________State_______ Zip _______

Confidential Mailing Address:_____________________________________________________

E-mail Address: ________________________________________________________________

Home Phone: ______________________ Work Phone: ________________________

Fax : _____________________________ Cell/Pager: __________________________

Alternate Contact: ______________________________________________________________

(Name and phone number of someone that can be contacted regarding this matter)

Date of Birth: _____________________ SSN: ______________________________

Employer: ________________________ Occupation: _________________________

Yearly salary: _____________________ Drivers License #_____________________

How paid (i.e., monthly, bimonthly, every two weeks, etc.)______________________________

My case concerns (Please check all that apply)

____ Custody ____ Child Support ____ Separation ____ Divorce

____ Spousal Support ____ Alimony ____ Equitable Distribution of property

Please briefly describe your legal question or situation: _________________________________

_____________________________________________________________________________

_____________________________________________________________________________

In order to avoid conflicts of interests, please state the name of your spouse or other third party

who is related to this situation: _________________________ His/her attorney______________

Have you seen an attorney previously: __________________ If so, when? _________________

How were you referred to this firm? ___ Friend: _________________________

___ Another Attorney: ____________________ ___ Another client: ___________________

___ Yellow pages: _______________________ ___ Other: __________________________

Information regarding children:

Name: _____________________ Date of Birth: _______________ SSN:_____________

Name: _____________________ Date of Birth: _______________ SSN:_____________

Name: _____________________ Date of Birth: _______________ SSN:_____________

Name: _____________________ Date of Birth: _______________ SSN:_____________

Information regarding the other party:

Full Name: ____________________________________________________________________

Address: ______________________________________________________________________

Home phone: _______________________ Work phone: _________________________

Date of Birth: _______________ SSN:________________ Yearly salary: ____________

Employer: _____________________________________________________________________

Please provide the following:

Date of Marriage: _______________________ Date of separation:

_______________________

County and state of marriage: _____________________________________________________

Is there a signed separation agreement? ___ yes ___ no If so, date signed: _________________

Is there a custody order in place? __ yes ___ no If so, date signed: _______________________

Is there a child support order in place? ___ yes ___ no If so, date signed: __________________

Is there a spousal support order in place? ___ yes ___ no If so, date signed:________________

(e.g. alimony/post separation support)

Is there a signed property agreement? ___ yes ___ no If so, date signed:___________________