Matrimonial Worksheet CLIENT: Name: ________________________________________________________________ Street Address: _________________________________________________________ State: ____________ Home Phone: ____________ Date of Birth: ____________ Race: ____________ Zip Code: _____________ County: ______________
Work Phone: ____________ State of Birth: ____________ Highest Level of Education: __________________
Number of this Marriage (1st Marriage, 2nd Marriage, etc): ________________________ If previously married, how many ended in death? ____ Divorce or Annulment? _______ Annual Gross Income: _______________ SPOUSE: Name: ________________________________________________________________ Street Address: _________________________________________________________ State: ____________ Home Phone: ____________ Date of Birth: ____________ Race: ____________ Zip Code: _____________ County: ______________ Social Security Number: _______________
Work Phone: ____________ State of Birth: ____________ Highest Level of Education: __________________
Number of this Marriage (1st Marriage, 2nd Marriage, etc): ________________________ If previously married, how many ended in death? ____ Divorce or Annulment? _______ Annual Gross Income: _______________ Wife’s Maiden Name: _______________ Social Security Number: _______________
Date of Marriage: _______________ County of Marriage: ________________
City/Town of Marriage: _______________ State of Marriage: ____________________
Was marriage performed by a clergyman, minister or leader of the Society for Ethical Culture? __________________ Approximate date of separation: _________ **Grounds for Divorce: _______________ Residence at a time of abandonment, cruel and inhuman treatment, etc: ______________ Date of abandonment, cruel and inhuman treatment, etc: __________________________ **Grounds for Divorce in New York State are: 1) Cruel and Inhuman Treatment 2) Abandonment 3) Confinement in Prison 4) Adultery 5) Living Apart One Year After Judgment of Separation 6) Living Apart One Year After Execution of a Separation Agreement CHILDREN: Full Name _____________ _____________ _____________ _____________ _____________ Date of Birth ___________ ___________ ___________ ___________ ___________ Custody ________ ________ ________ ________ ________ Social Security Number ___________________ ___________________ ___________________ ___________________ ___________________
Child Support Paid to: (check one) Wife: ______ Husband: ______ Third Party: ______
Amount of Child Support: ____________
**If you have a Family Court Order of Support and/or Custody, please enclose a copy.**
Other Addresses for children within the last five (5) years:
Street: ______________________ City, State, Zip: ______________ Street: ______________________ City, State, Zip: ______________ Mother’s Health Insurance Information: Group Health Plan: ______________ Address: ______________________ I.D. #: ________________________ Plan Administrator: ______________ Type of Coverage: _______________ Martial Home: owned ____________ Value of Home (if owned): ________
Street: ______________________ City, State, Zip: ______________ Street: ______________________ City, State, Zip: ______________ Father’s Health Insurance Information: Group Health Plan: ______________ Address: ______________________ I.D. #: ________________________ Plan Administrator: ______________ Type of Coverage: _______________ rented ____________ Outstanding Mortgage: ____________
Post divorce occupancy of marital home (check one): husband ___ wife ___ neither ___