Date: ________________

Full Name (Last, First, Middle): _____________________________________________

Date of Birth: _____________ Age: _____ Birthplace: ____________________

Social Security #: _________________ Driver’s License #: ______________ State: ____

Full Current Address: ________________________, _________________, _________

COUNTY OF RESIDENCE: ________________________

Mailing Address (if a different from above): ___________________________________

Home Phone: _________________ Work Phone: ____________________

Pager: ___________________ Cell: ______________ E-Mail: _____________________

How do you prefer we contact you ? _________________________________

Have you been a resident of this county for longer than three months ? Yes No

Have you been a resident of Texas for longer than six months ? Yes No

Occupation: ___________________________________

Employer: ___________________________________

Address of Employment: _________________________________________

Education: ___________________________________

Your gross salary per month or year: $ ____________ Length of Employment: _______

Who referred you to this office? _____________________________________________

Have you seen a marriage counselor? _______ State name: _______________________

Have you or your spouse ever filed for divorce? _________

If so, when and where? ____________________________________________

Does you spouse or ex-spouse have an attorney? ______ State name: ________________

Have you ever been married before? ________ If so, how many times? ________

Will either party be requesting a name change ? Yes No

If yes, what will the new name be ? (Full name) _______________________________

What is your religious preference? ___________________________________________

If none, are you agnostic or atheist? __________________________________________

Name (Last, First, Middle): _________________________________________________

Date of Birth: __________ Age: _____ Birthplace: ______________________________

Social Security #: _________________ Driver’s Lic. #: _________________ State: ____

Full Current Address: __________________________ , _____________ , ___________

COUNTY OF RESIDENCE: __________________

Residence Telephone #: _________________

Occupation: _______________________________

Employer: ______________________________

Address of Employment: ___________________________

Employer phone #: ________________________

Education: ____________________________

Spouse’s gross salary monthly/annual: $ ____________ Length of employment________

Date of Marriage: ________________

Place of Marriage: ________________

Date of Separation: _______________

What is your spouse’s or ex-spouse’s religious preference? ________________________

If none, is your spouse or ex-spouse agnostic or atheist? ________________________

Check as appropriate if you marital difficulties involve any of the following:

____ drug/alcohol ____ Sexual disappointment ____ infidelity

____ financial dispute ____ physical violence ____ religion

____ Incompatibility ____ other: ________________________________

Separate Property: Do you own any separate property (property owned before marriage or property received during marriage by gift or inheritance)? Y N

Does your spouse own any separate property? (Circle one) Yes No

Income Tax: Have you filed for all previous years ? (Circle one) Yes No

Name: ___________________________________ Sex: _____________

Date of Birth: _________________ Age: _____ Birthplace: ______________________

Social Security #: ________________________ Drivers Lic. #: ___________________

Name: ___________________________________ Sex: _____________

Date of Birth: _________________ Age: _____ Birthplace: ______________________

Social Security #: ________________________ Drivers Lic. #: ___________________

Name: ___________________________________ Sex: _____________

Date of Birth: _________________ Age: _____ Birthplace: ______________________

Social Security #: ________________________ Drivers Lic. #: ___________________

Name: ___________________________________ Sex: _____________

Date of Birth: _________________ Age: _____ Birthplace: ______________________

Social Security #: ________________________ Drivers Lic. #: ___________________

Who will have primary custody of the children? (Circle one) Father Mother Other

If "Other" please state name and relationship (if any) ____________________________

Will the parties have joint custody? (Circle one) Yes No

Which parent will be paying child support? (Circle one) Father Mother

Amount of child support (if agreed) $ _________________ per month.

(Note: In an uncontested divorce, the parties can agree on any figure for child support,

and the judge will probably approve it. However, the Texas Family Code contains child support guidelines that are generally used. If the parties wish to base support on the guidelines, advise the attorney. He will determine that figure for you, based on the obligor (person paying child support) parent’s income and number of other children for which the obligor parent is providing support.)

Which parent will be responsible for the children’s health insurance? Father Mother

(Note: The parent who pays child support generally is also responsible for maintaining health insurance on the children. The parents usually split medical expenses not paid by insurance.)

Do you pay/receive child support? _______ If so, how much? $_________ per________

Does your spouse or ex-spouse pay/receive child support? ______________

If so, how much? _____________ per ____________

Do you or your spouse or ex-spouse have any other children for which a duty of support

is owed? __________ If so, please state the following information:

Name: ______________________________ Sex: _____

Date of Birth: ________________ Age: ____ Birthplace: _________________________

Social Security #: ___________________ Driver’s Lic. #:________________ State:____

Name: ______________________________ Sex: _____

Date of Birth: ________________ Age: ____ Birthplace: _________________________

Social Security #: ___________________ Driver’s Lic. #:________________ State:____

Name: ______________________________ Sex: _____

Date of Birth: ________________ Age: ____ Birthplace: _________________________

Social Security #: ___________________ Driver’s Lic. #:________________ State:____

_______________________________________________________________________

PROPERTY FORM GIVEN TO CLIENT: š YES š NO

PROPERTY FORM TO BE RETURNED: š YES š NO

PROPERTY FORM NOT NEEDED: š YES š NO

ADR STATEMENT: š YES š NO