Provide Your Information

Full Name:

Street Address:

City:

County:

State:

Zip:

Work Phone:

Home Phone:

Email: (optional) 

Are you currently in the military:

- Select One - Yes No

Provide Your Spouse's Information

We will NOT contact your spouse.

Spouse's Name:

Street Address:

City:

State:

Zip:

Work Phone:

Home Phone:

Is your spouse currently in the military:

- Select One - Yes No

Provide The Following Marriage Information

Date of Marriage:

Place of Marriage:

Separation Date:

Is Alimony to be Paid?

- Select One - Yes No

If yes, please enter the amount:

$

Alimony to be paid by:

- Select One - Husband Wife

To the best of your knowledge, is your combined income with your spouse above or below $50,000/year.

Above

Below

Provide Property and Debt Information

Husband transfers to Wife the following property and or assets:

Wife transfers to Husband the following property or assets:

Husband shall be responsible for paying the following debts:

Wife shall be responsible for paying the following debts:

* Please specify credit cards by the name of the issuing bank.

Wife's Former Name

Wife requests to have former name restored: - Select One - Yes No

Please indicate former name:

Provide Minor Children Information

Names and Birthdates of Minor children you have with your spouse. Please include M (male) F (female) for each child.

List all addresses where the children have lived in the past 5 years:

Child Custody Information

Please indicate whether there has ever been any court proceeding prior involving the custody or support of the minor children. Please include the court and case number of any such proceeding:

Please indicate which spouse will have Primary custody of the minor children:

- Select One - Husband Wife

Please indicate whether visitation should be listed as:

- Select One - Liberal Supervised Scheduled Restricted

If you indicated that visitation was to be "Supervised" or "Restricted" Please specify the terms of such visitation here:

Child Support Information

Please indicate the agreed upon amount for child support:

$ /per month

To be paid by:

- Select One - Husband Wife

OR

Would you prefer the amount of child support left blank so that the court may set it or you and your spouse may discuss an agreed upon amount and enter it on the form?

- Select One - Let Court Specify As Specified Above

Medical insurance coverage for the minor children to be provided by:

- Select One - Husband Wife Medicaid None

Payment Information

Name on card:

Billing Address:

City:

State:

Zip:

Card Type:

Master Card Visa

Card Number:

We cannot complete your divorce until credit card information is provided.

3 digit security code on back of card:

Expiration Date: