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DIVORCE MEDIATION IN-TAKE FORM

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DIVORCE MEDIATION IN-TAKE FORM Powered By Docstoc
					                    ASSETS, LIABILITIES, INCOME AND BUDGET
                                  WORKSHEET



YOUR NAME ________________________________
SPOUSE’S NAME______________________________

ASSETS                                                                        VALUE

Please make an estimate of market value for each asset, and write it on the
short line on the right hand side.

Homestead
Address: ________________________________________________________
Estimated Market Value of Property Today:                                     _______
Other Factors that might affect the value of the house:                       _______
Present Mortgage Balance:                                                     (______)
Second Mortgage Balance:                                                      (______)
Other Liabilities that Decrease the Value of the Home                         (______)



Other Real Estate
____________________________________________________________                  _______
____________________________________________________________                  _______
____________________________________________________________                  _______
____________________________________________________________                  _______
____________________________________________________________                  _______
____________________________________________________________                  _______
                                                                                       2


Other Personal Assets
Bank Accounts
       Savings Accounts (Bank name, account number)
       _____________________________________________________                 _______
       _____________________________________________________                 _______

       Certificates of Deposit (Bank name, account number)
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______

       Checking Accounts (Bank name, account number)
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______

Stocks (Company, number of shares, in whose name)
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______

Bonds (Issuer, type)
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______
       _____________________________________________________                 _______

Any property owned by you or your spouse, but held by someone else:
      ______________________________________________________                 _______
      ______________________________________________________                 _______
      ______________________________________________________                 _______

Life insurance (insurance company, policy number, on life of, beneficiary)
        ______________________________________________________               _______
        ______________________________________________________               _______
        ______________________________________________________               _______
        ______________________________________________________               _______
                                                                                                3


Retirement plans (employer, percent vested)
       _____________________________________________________                         _______
       _____________________________________________________                         _______
       _____________________________________________________                         _______

IRA Accounts (held by whom, account number)
      _____________________________________________________                          _______
      _____________________________________________________                          _______
      ______________________________________________________                         _______

Other Intangible Property, such as patents, contractual rights, etc. (description)
       _______________________________________________________                       _______
       _______________________________________________________                       _______
       _______________________________________________________                       _______
       _______________________________________________________                       _______

Motor Vehicles (year, model, make)
      _______________________________________________________                        _______
                                   balance of loan on vehicle:                       (______)
      _______________________________________________________                        _______
                                   balance of loan on vehicle:                       (______)
      _______________________________________________________                        _______
                                   balance of loan on vehicle:                       (______)

Furniture (description)
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______

Appliances (description)
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
Other household furnishings
       ______________________________________________________                        _______
       ______________________________________________________                        _______
       ______________________________________________________                        _______
                                                                                   4


Tools and yard equipment
       ______________________________________________________            _______
       ______________________________________________________            _______
       ______________________________________________________            _______

Collectibles not mentioned above
       ______________________________________________________            _______
       ______________________________________________________            _______
       ______________________________________________________            _______
       ______________________________________________________            _______

Ownership of privately held businesses (description)
___________________________________________________                      _______
___________________________________________________                      _______
___________________________________________________                      _______
___________________________________________________                      _______




DEBTS (ONLY LIST THOSE NOT MENTIONED ABOVE)                          AMOUNT OWED

Credit Cards (issuer, type of card, account number, in whose name)
______________________________________________________                   _______
______________________________________________________                   _______
______________________________________________________                   _______
______________________________________________________                   _______

Other Debts (including loans from family members)
______________________________________________________                   _______
______________________________________________________                   _______
______________________________________________________                   _______
______________________________________________________                   _______
                                                                               5


EXPENSES                                               MONTHLY AMOUNT

                                                       for self   for child(ren)
Rent or mortgage payment                               _______
Utilities:
        Heat/fuel                                      _______
        Electricity                                    _______
        Water                                          _______
        Gas (if separate from heat)                    _______
Phone                                                  _______    _______
Cell phone                                             _______    _______
Pager                                                  _______    _______
Cable TV                                               _______    _______
Internet Access                                        _______    _______
Home Maintenance                                       _______
Motor Vehicles:
        Loan or Lease payments                         _______    _______
        Insurance                                      _______    _______
        Gas and oil                                    _______    _______
        Other vehicle maintenance                      _______    _______
        License                                        _______    _______
Regular Dept Payments (description)
        _____________________________________          _______
        _____________________________________          _______
        _____________________________________          _______
Child Support or Spousal Maintenance Obligation from
        Other Relationships                            _______
Food                                                   _______    _______
Meals eaten out                                        _______    _______
Lunches at work or school                              _______    _______
Entertainment                                          _______    _______
Grooming products, haircuts                            _______    _______
Clothes                                                _______    _______
Laundry                                                _______    _______
Dry Cleaning                                           _______    _______
Daycare                                                           _______
Uncovered Medical:
        doctor                                         _______    _______
        dentist                                        _______    _______
        other provider                                 _______    _______
        medication                                     _______    _______
Medical Insurance                                      _______    _______
Life Insurance                                         _______
Homeowner’s / Renter’s Insurance                       _______
Charitable Contributions                               _______    _______
                                                                                          6


Gifts                                                                          _______
Union or Professional Dues                                           _______
Social Club Dues                                                     _______   _______
Health Club Dues                                                     _______   _______
Religious Dues                                                       _______   _______
Reading Materials                                                    _______   _______
Travel                                                               _______   _______
Education (books, tuition, school activities, transportation)        _______   _______
_____________________________                                        _______   _______
_____________________________                                        _______   _______
Tutoring                                                             _______   _______
Other Classes or Lessons                                             _______   _______
Allowance                                                                      _______
Sports Equipment                                                     _______   _______
Pet expenses                                                         _______   _______
Other expenses:
       _______________________________                               _______   _______
       _______________________________                               _______   _______
       _______________________________                               _______   _______
       _______________________________                               _______   _______
       _______________________________                               _______   _______




Now that you’ve listed your monthly expenses, please list again the following expenses,
which may be tax-deductible. Please list these as YEARLY amounts here:

Medical expenses that you pay for yourself and your children                   ______
Mortgage interest                                                              ______
Charitable contributions                                                       ______
Deductible business expenses                                                   ______
Spousal maintenance that you pay from another relationship                     ______
Other deductible expenses (describe)
_______________________________________________________                        ______
_______________________________________________________                        ______
_______________________________________________________                        ______
_______________________________________________________                        ______



INCOME
(Please list gross income, and bring any pay stubs to the next session).       _______

				
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