Instructions: 1. Print out this form; 2. Complete all of the information requested; 3. fax the form to 713-968-9277 (if paying by credit card) – or mail the completed form with a check for the appropriate amount to the Law Offices of Gregory T. Josefsberg, 5100 Westheimer, Suite 200, Houston, TX 77056. CLIENT QUESTIONNAIRE Please complete this questionnaire. If you will spend the time to complete all items, you will give us the background information necessary to start producing the documents you need to get a divorce. All information will be held in strict confidence. 1. Your information a. I am the ________________________ of the marriage.
Wife or Husband
b. Name:
____________________________________________ ________________________________ ________________________________
c. Social Security number: d. Driver’s license number: e. Street address: f. City, State, zip:
______________________________________ ______________________________________ __________________________
g. Residence telephone number:
h. Cellular telephone number: ________________________________ i. I prefer to be contacted via (circle one):
email home phone
work phone
cellular phone
j. Email address:
_________________@___________________
k. Employer: ____________________________________________ l. Employer address: ______________________________________ m. City, State, zip: n. Work number: ______________________________________ ______________________________________
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o. Gross salary per month:
$_______________________________
p. Date of birth:__________________ in city, state:_______________ 2. Spousal Information a. Name: ____________________________________________ ________________________________ ________________________________ ________________________________
b. Social Security number: c. Driver’s license number: d. Spouse’s street address: e. City, State, zip:
______________________________________ __________________________
f. Residence telephone number:
g. Cellular telephone number: ________________________________ h. Employer: ____________________________________________ i. Employer address: ______________________________________ j. City, State, zip: k. Work number: ______________________________________ ______________________________________ $_______________________________
l. Gross salary per month:
m. Date of birth:__________________ in city, state:______________ 3. Details of the Marriage a. Date of marriage: ______/______/______ ___________________________
b. Place of marriage (city, state):
c. Is there a prenuptial (premarital), or postnuptial agreement? __________________ d. Date of Separation: ______/______/______ 4. Children of Current Marriage that are under 19 yrs old or are still enrolled in school (have not graduated from high school) a. Name: _____________________________________________ sex (M/F)
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Date of birth: _______/_______/_______ Place of birth: Driver’s license number (state): b. Name:
_____________________
____________________________
_____________________________________________ sex (M/F) _____________________
Date of birth: _______/_______/_______ Place of birth: Driver’s license number (state): c. Name:
____________________________
_____________________________________________ sex (M/F) _____________________
Date of birth: _______/_______/_______ Place of birth: Driver’s license number (state): d. Name:
____________________________
_____________________________________________ sex (M/F) _____________________
Date of birth: _______/_______/_______ Place of birth: Driver’s license number (state):
____________________________
e. Children currently live with (husband or wife)? ________________________ f. After the divorce, children will live with (husband or wife)? ____________ ____________
g. Both parents agree to the Texas Standard Possession Order (yes/no)?
If both parents do not agree to the Texas Standard Possession Order, you are not eligible for this program. The Texas Standard Possession Order may be found in § 153 of the Texas Family Code. h. How much child support will be paid per month? $______________ § 154 of the Texas Family Code contains the Texas child support guidelines. i. Are the children covered by health insurance (yes/no)? _______________
If so, whose plan (husband/wife or State of Texas)? _________________________ Policy Number: ____________________________________
Will insurance continue after the divorce (yes/no)? ___________________ j. List all property (other than furniture and clothing) owned by the children:
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_____________________________________________________________ _____________________________________________________________ 5. Family History a. How long have you lived in Texas? b. What county do you reside in? _________________________
_______________________________
c. How long have you lived in that county? _________________________ d. How long has your spouse lived in Texas? _________________________ e. What county does s/he reside in? _______________________________ f. How long has s/he lived in that county? ____________________________ g. Have you or your spouse ever filed for divorce from this marriage?______ h. If so, when and where? _____________________________________
i. Have you been married before? _________ If so, how many times? _____ j. Do you have children by a previous marriage? ______ k. If so, please provide the following information regarding each child of your previous marriages: Name: Date of Birth Birth City, State
A. __________________________ _______/_______/_______ __________________ B. __________________________ _______/_______/_______ __________________ C. __________________________ _______/_______/_______ __________________ D. __________________________ _______/_______/_______ __________________ i. With whom do these children reside? _________________________
j. Do you receive/pay child support? __________ If so, how much? $_____________per____________
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k. Has your spouse been married before? __________ If so, how many times? ________ l. Does your spouse have children from a previous marriage? ____________ m. If so, please provide the following information regarding each child of your spouse’s previous marriages: Name: Date of Birth Birth City, State
A. __________________________ _______/_______/_______ __________________ B. __________________________ _______/_______/_______ __________________ C. __________________________ _______/_______/_______ __________________ D. __________________________ _______/_______/_______ __________________ n. With whom do these children reside? _________________________
o. Does your spouse receive/pay child support? __________ If so, how much? $_________per____________ 6. Legal Representation a. Do your or your spouse have an attorney? _________________________ b. If so, who? _________________________________________________ 7. Name Change of Wife a. If a divorce is granted, should the wife’s maiden or prior name be restored? ________ b. If so, what name should be used? __________________________________ 8. Summary of Property a. Real Estate: I. Address: ______________________________________________________
Mortgage Company: ________________________________________________ Mortgage Balance: $__________________ Monthly payments: $___________
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Estimated fair market value: $_________________ Year bought: ____________ Who gets this (husband or wife)? II. Address: ___________________
______________________________________________________
Mortgage Company: ________________________________________________ Mortgage Balance: $__________________ Monthly payments: $___________
Estimated fair market value: $_________________ Year bought: ____________ Who gets this (husband or wife)? ___________________
III. Address: ______________________________________________________ Mortgage Company: ________________________________________________ Mortgage Balance: $__________________ Monthly payments: $___________
Estimated fair market value: $_________________ Year bought: ____________ Who gets this (husband or wife)? ___________________
b. Motor Vehicles (Cars, Boats, Airplanes, Motorcycles, Trailers, etc.) I. Year: _________ Make/Model: _________________ Who Drives? _________ Loan with: _______________________________________________________ Year bought: ____________________
Loan balance: ______________________ Who gets this (husband or wife)?
___________________
II. Year: _________ Make/Model: _________________ Who Drives? _________ Loan with: _______________________________________________________ Year bought: ____________________
Loan balance: ______________________ Who gets this (husband or wife)?
___________________
III. Year: _________ Make/Model: _________________ Who Drives? _________ Loan with: _______________________________________________________
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Loan balance: ______________________ Who gets this (husband or wife)?
Year bought: ____________________
___________________
IV. Year: ________ Make/Model: _________________ Who Drives? _________ Loan with: _______________________________________________________ Year bought: ____________________
Loan balance: ______________________ Who gets this (husband or wife)?
___________________
V. Year: _________ Make/Model: _________________ Who Drives? _________ Loan with: _______________________________________________________ Year bought: ____________________
Loan balance: ______________________ Who gets this (husband or wife)?
___________________
c. Cash and Savings (bank accounts, savings accounts, C.D.’s, credit union, savings bonds) I. Name of bank: Type of account: _________________________________________________ _________________ Amount on Deposit: $_____________
Names on withdrawal card: ___________________________________________ Who gets this (husband, wife, or split)? II. Name of bank: Type of account: ___________________
_________________________________________________ _________________ Amount on Deposit: $_____________
Names on withdrawal card: ___________________________________________ Who gets this (husband, wife, or split)? III. Name of bank: Type of account: ___________________
_________________________________________________ _________________ Amount on Deposit: $_____________
Names on withdrawal card: ___________________________________________
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Who gets this (husband, wife, or split)? IV. Name of bank: Type of account:
___________________
_________________________________________________ _________________ Amount on Deposit: $_____________
Names on withdrawal card: ___________________________________________ Who gets this (husband, wife, or split)? d. Life insurance I. Name of Company: ________________________________________________ Insuring life of: _____________________ Cash surrender value: $___________ Who gets this (husband, wife, or split)? II. Name of Company: ___________________ ___________________
__________________________________________
Insuring life of: _____________________ Cash surrender value: $___________ Who gets this (husband, wife, or split)? III. Name of Company: ___________________
__________________________________________
Insuring life of: _____________________ Cash surrender value: $___________ Who gets this (husband, wife, or split)? IV. Name of Company: ___________________
__________________________________________
Insuring life of: _____________________ Cash surrender value: $___________ Who gets this (husband, wife, or split)? e. Stocks, Bonds, Mutual Funds I. Name of Broker/Brokerage House (ex: Ameritrade, eTrade, Smith Barney, Schwab): ______________________________________________________________________ Estimated value: $___________________ List the names of stock (ex: 150 shares of Ford, 200 shares of Fidelity Magellan Fund): ___________________
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______________________ ______________________ ______________________
______________________ ______________________ ______________________
_______________________ _______________________ _______________________
Who gets this (husband, wife, or split)?
___________________
II. Name of Broker/Brokerage House (ex: Ameritrade, eTrade, Smith Barney, Schwab): ______________________________________________________________________ Estimated value: $___________________ List the names of stock (ex: 150 shares of Ford, 200 shares of Fidelity Magellan Fund): ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ _______________________ _______________________ _______________________
Who gets this (husband, wife, or split)? f. Other Property
___________________
Generally, the husband and wife will be awarded all personal property in his or her own possession (household goods, clothes, jewelry, electronics, etc.). However, you may list some items individually if you would like these items specifically listed in the divorce decree: Item & Description Who has possession now ___________ ___________ ___________ ___________ ___________ Who gets this item after the divorce _________________ _________________ _________________ _________________ _________________
______________________________ ______________________________ ______________________________ ______________________________ ______________________________
g. Retirement, Pensions, Other Company Benefits
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Under this program, the husband and wife keep 100% of their retirement benefits. Should you desire a split of these assets, you are not eligible for this program. I. Do you participate in any retirement plan? _______________ Does your spouse participate in any retirement plan? ____________________ II. Do you participate in any company savings plan? _____________ Does your spouse participate in any company savings plan? ____________________ h. Does anyone owe you or your spouse any money? __________ If so, how much? $______________ Owed by whom? _______________________ Who gets this (husband, wife, or split)? ___________________
i. Do you own any livestock or mineral interests? ___________________________ Who gets this (husband, wife, or split)? ___________________
j. Do you belong to any clubs with an equity interest? ________________________ Who gets this (husband, wife, or split)? ___________________
k. Debts (Other than house and/or automobiles) (Be specific): Name of Creditor:_______________________ Balance: $ ________________
Name(s) on Account: ___________________________________________ Who is responsible after divorce? _______________________________ Balance: $ ________________
Name of Creditor:_______________________
Name(s) on Account: ___________________________________________ Who is responsible after divorce? _______________________________ Balance: $ ________________
Name of Creditor:_______________________
Name(s) on Account: ___________________________________________ Who is responsible after divorce? _______________________________ Balance: $ ________________
Name of Creditor:_______________________
Name(s) on Account: ___________________________________________
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Who is responsible after divorce?
_______________________________ Balance: $ ________________
Name of Creditor:_______________________
Name(s) on Account: ___________________________________________ Who is responsible after divorce? _______________________________ Balance: $ ________________
Name of Creditor:_______________________
Name(s) on Account: ___________________________________________ Who is responsible after divorce? l. Income Taxes Are you expecting an income tax refund (yes/no)? ________________ Who will get this after the divorce (husband, wife, or split)? __________ m. Tax liabilities (Federal, State, and local) Describe any current tax liability (Be specific):________________________________ ______________________________________________________________________ ______________________________________________________________________ Who will be responsible for the tax liability after the divorce? 9. Other Relevant Information: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 10. Qualification: You must agree to each of the following statements by initialing in each space provided: ________________ _______________________________
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a. ________ I have lived in Texas for at least 6 months and in the county where I will file for at least 90 days, or I live outside of Texas and my spouse has lived in Texas for at least 6 months. b. ________ Neither me nor my spouse has already filed for divorce. c. ________ There aren't any temporary orders, protective orders, or temporary injunctions pending in any court, including any orders dealing with child custody or support. d. ________ There aren't any allegations of family violence. e. ________ My spouse will waive all of his/her rights to contest the terms of the divorce. f. ________ ALL community (marital) property and community (marital) debt is listed on this form. g. _______ The wife of the marriage is not expecting a child. h. ________ I understand that I must appear in court before a judge to finalize my divorce. i. _________ I understand that the documents will be prepared using the information that I provide in this form and that no research or investigation will be performed on my behalf. j. ________ I understand that I must pay all for all court and filing fees associated with my divorce. k. _______ I understand that me and my spouse are NOT: A) creating an attorney-client relationship, B) entitled to any legal advice, C) entitled to any attorney to appear or represent either of us for any purpose including an appearance in court. 11. Fees and Method of Payment: a. Texas Divorce Forms Kit - No Children, no property/debt: $149.00 b. Texas Divorce Forms Kit – No Children, with property/debt: $199.00 c. Texas Divorce Forms Kit – With Children, no property/debt: $299.00 d. Texas Divorce Forms Kit – With Children, with property/debt: $399.00 The above forms kits include all of the following: ______ ______ ______ ______
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A) B) C) D) E)
Original Petition for Divorce; Waiver of Citation; Final Decree of Divorce; Prove-up Testimony; and How to use the forms instructions.
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e. Closing documents: A) Power of Attorney (motor vehicle): B) Special Warranty Deed: _______x $49.00 ea. = _______x $99.00 ea = ______ ______ ______
C) Deed of Trust to Secure Assumption: _______x $99.00 ea = f. Preparation Time - Check one of the following: ______A) By the end of the 3rd business day FREE ______B) Rush Service - By the end of the 2nd business day: + $50.00 ______C) Super Rush Service - By the end of the next business day + $100.00 g. Delivery - Check one of the following:
______ ______ ______
+ ______A) e-mail delivery to: _________________@________________ FREE ______B) pick-up at office FREE ______C) First Class U.S. Mail Delivery: + $3.00 ______ ______D) USPS Priority Mail (1-3 days): + $5.00 ______ ______E) USPS Express Mail (1-day): + $20.00 ______ e. TOTAL: I AUTHORIZE MY CREDIT OR ATM CHECK CARD TO BE CHARGED: f. Circle one: MasterCard Visa AMEX Discover Card Number: ______________________ 12. Signature: Expiration Date: ___________________
$___________
___________________________________ Signature
________/______/______ Date
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