Non-Profit Case Questionnaire

FAMILY LAW INTAKE

Please fill out this questionnaire. It is important that you answer each question fully because your attorney will use this information to prepare your case. Your responses to these questions will help to organize your case and allow our firm to better represent you. If a question does not apply to your particular situation, please indicate by marking the question “N/A”. Your answers are protected by confidentiality and by the attorney-client privilege, but please note that a legal consultation does not establish on ongoing attorney-client relationship and that neither the attorney nor you have any obligation to accept or offer any additional services. You are free to have the presence of a third party (or parties) present during your consultation, but please note that doing so constitutes your waiver of attorney-client privilege as to anything discussing during the consultation, meaning that anything discussed could potentially be discoverable in litigation. NOTE: There is a flat fee of $200.00 for the initial, forty-five (45) minute consultation. If you have any questions about this fee, please discuss it with the attorney before beginning the consultation. I understand that a legal consultation does not establish an ongoing attorney-client relationship and that neither the attorney nor I have any obligation to accept or offer any additional services. I understand that the presence of a third party during this consultation constitutes a waiver of attorney-client privilege as to anything discussed during this consultation and that anything discussed could be potentially discoverable in litigation. I understand and agree that the firm charges a flat fee of $200.00 for the initial, forty-five (45) minute consultation. I agree to pay said fee before the start of the initial consultation. I understand that if a do not retain the attorney within 60 days of this consultation, a second consultation may be required.

Today's Date *

Signature *

Reset Signature

Signature is required.

Prospective Client Info

Name *

Date of Birth *

SSN: ___ - __ - ___ *

Address *

Apt, suite, etc.

Country

City

State

Zip code

How Long Have You Lived in North Carolina? *

Email *

Cell Phone # *

Alternate Phone #

Okay to leave messages at these phone numbers? *

Yes

Only on Cell Phone

Only on Alternate Phone

YOUR EMPLOYER: *

Position *

Income: *

Salary

Hourly

Other

If self-employed, Company & Type of Business (LLC, Corp, etc) *

Reason for your Consultation: *

Have you Consulted or Retained Another Lawyer? (check all that apply) *

Consulted

Retained

If Yes, Who?

If referred by someone or an attorney, who can we thank?

Opposing Party Info

Name *

Date of Birth

SSN: ___ - __ - ___

Address *

Apt, suite, etc.

Country

City

State

Zip code

How Long Have They Lived in NC? *

Email *

Cell Phone *

Secondary Phone

Employer: *

Income: *

Salary

Hourly

Other

Stock Options, Bonuses, Paid for Benefits, Etc? (If none, please put none) *

If Self-Employed, Company & Type of Business (LLC, Corp, etc):

Opposing Party's Attorney:

Marriage Information

(Concerning the Marriage out of which your Present Issues Arise)

Marriage Date: *

County / State Married: *

Currently Separated?

Yes

If Separated, Date of Separation?

Reason for Separating?

Separation Agreement?

Yes

N/A

If Yes, Date Separation Agreement Signed?

If seeking a Divorce, do you wish to resume your Maiden Name?

Yes

N/A

If Yes, Please State Full Maiden Name:

Children

(Including those Children Not Involved in the Present Issue)

If Children, Please Include the Following Information for Each Child:

1. FULL NAME; 2. AGE; 3. SEX: 4. FATHER: 5. On Birth Certificate:

Child Custody

Is Child Custody in Dispute?

Yes

If YES, Please Explain:

Do you have a Current Child Custody Order?

Yes

If YES, Please Provide Us the Following Information:

1. DATE OF OTHER: 2. COUNTY OF ORDER: 3. TERMS:

Is the Order Being Followed?

Yes

If NO, Please Explain:

If there is NO court Order (or if different) but support is being paid via agreement, what are the terms?

How Long Have You Been Operating Under this Agreement?

Child Support

Is Child Support in Dispute?

Yes

If Yes, Please Explain:

Do you have a Current Child Support Order?

Yes

If YES, Please Answer the Following:

1. DATE: 2. COUNTY OF ORDER: 3. AMOUNT PER MONTH:

Are You Receiving or Paying?

Receiving

Paying

Arrears Amount:

If there is NO Court Order (or if different) but support is being paid via agreement, what are the terms?

How Long Have You Been Operating Under This Agreement?

Property Distribution

(assets, debts, inheritances, etc., that will need to be distributed pursuant to divorce/separation)

Martial Residence

Address of Marital Residence

Apt, suite, etc.

Country

City

State

Zip code

Who Left or Who Will Be Leaving the Marital Residence?

Do You Rent or Own?

Rent

Own

If You OWN, Tell us the following about the Marital Home

1. Titled To: 2. Year Purchased: 3. Value: 4. Mortgage Balance: 5. Person(s) on Mortgage

Other Real Estate Owned by You and/or Your Spouse (include timeshares):

Please include the following information: 1. Titled To; 2. Property Address; 3. Market Value; 4. Mortgage Balance

Vehicles (include Mobile Homes if titled, motorcycles, ATV's, boats, etc.):

Do you have the following accounts?

IRA

401K

Pension

Estimated Balance of These Accounts:

Does Your Spouse Have the Following Accounts?

IRA

401K

Pension

Estimated Balance of Your Spouse's Accounts:

If you have investment accounts (stocks, etc.), What is the estimated balance of your investment accounts?

If Your Spouse has Investment Accounts, What is the Estimated Balance?

Expected Inheritance?

To Whom and What is the Anticipated Amount?

Do You Have any Frozen or Stored Embryos or Other Genetic Material?

Yes

Does your Spouse Own any Compromising or Explicit Photos or Videos of You?

Yes

DEBTS (Include Credit Cards, Student Loans, Personal Loans, Home Equity Lines, etc.):

Please include the following information: 1. Account Name & 2. Approximate Balance for Each Debt

Other Case Info

Please Check All That Apply:

I have been Served with a Lawsuit

I want a Separation Agreement

I want a Restraining Order

I want to Pursue Contempt for Violation of a Court Order

If you've been served with a Lawsuit, what Date were you served?

If you want a Separation Agreement. Do both parties agree or not agree to the terms?

We Agree

We Do Not Agree

If you want a restraining order. What is the Reason?

ANYTHING ELSE WE SHOULD KNOW? Fill in any additional information here:

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