Family - Custody et al Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth Other Parent's Name First Name Last Name Other Parent's Phone (###) ### #### Other Parent's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Other Parent's Date of Birth MM DD YYYY Employer name, phone, and address Other Parent's employer name, phone, and address Name, Date of Birth, and Residence of each minor child Do you have health insurance? Is so, name of carrier and policy number Will there be a dispute over cusotdy? What is your approximate yearly gross income? What is the other parent's approximate yearly gross income? Are there any current visitation and/or custody court orders in place? If so, please explain: Is there a history of domestic violence? If so, please explain: Are there any current criminal charges against you or the other parent? If so, please explain: Who lives with you? Who lives with the other parent? What would be your ideal custody and visitation schedule? Explain the dates, times, and pick-up/drop-off arrangement you would prefer. What are the children's school schedule? Would you have the ability to pick-up and/or drop-off the children at school and/or to their extracurricular activities? Do the children have any mental or physical hardships? Debt # 1 other than credit card (mortgage, car loan, student loan, other loans or judgments) Debt # 2 other than credit card (mortgage, car loan, student loan, other loans or judgments) Debt # 3 other than credit card (mortgage, car loan, student loan, other loans or judgments) Debt # 4 other than credit card (mortgage, car loan, student loan, other loans or judgments) Debt # 5 other than credit card (mortgage, car loan, student loan, other loans or judgments) Home monthly expenses: gas, light, trash, rent, mortgage, health care insurance, auto insurance, phone, groceries, clothes, internet, education, and/or any other monthly expenses. Thank you!
