DELANEY, McCARTHY & COLTON, P.C.

DOMESTIC RELATIONS INTAKE FORM

DATE:___________________________

HOME PHONE: (       )                            
WORK PHONE: (___)_______________

HUSBAND:

	FULL NAME:__________________________________________________
	SOCIAL SECURITY NUMBER:_____________________________________
	DRIVER’S LICENSE NUMBER:__________________ STATE:_________
	PLACE OF BIRTH (city/state/country):________________________
	DATE OF BIRTH:____________________
	
	EDUCATION
		HIGHEST GRADE COMPLETED (0-12):__________
		COLLEGE (1-4 or 5+):                              
	NUMBER OF THIS MARRIAGE:________
	FOR PREVIOUS MARRIAGE(S), HOW MANY ENDED BY:
		DEATH?                       
		DIVORCE OR ANNULMENT?__________
	USUAL RESIDENCE ADDRESS:
		STREET:________________________________________________
		CITY/COUNTY/STATE/ZIP:_________________________________
	LENGTH OF TIME AT THIS ADDRESS:_______IN VIRGINIA:______

WIFE:

	FULL NAME:                                                                           
	FORMER/MAIDEN NAME:_________________________________________
	SOCIAL SECURITY NUMBER:_____________________________________
	DRIVER’S LICENSE NUMBER:                                                 STATE:             
	PLACE OF BIRTH (city/state/country):________________________
	DATE OF BIRTH:____________________
	
	EDUCATION
		HIGHEST GRADE COMPLETED (0-12):__________
		COLLEGE (1-4 or 5+):______________
	NUMBER OF THIS MARRIAGE:                     
	FOR PREVIOUS MARRIAGE(S), HOW MANY ENDED BY:
		DEATH?__________
		DIVORCE OR ANNULMENT?                    
	USUAL RESIDENCE ADDRESS:
		STREET:________________________________________________
		CITY/COUNTY/STATE/ZIP:                                                              
	LENGTH OF TIME AT THIS ADDRESS:_                   ______IN VIRGINIA:__                ____

MARRIAGE:

	DATE:                           
	PLACE (city/county/state/country)___________________________
	HAVE YOU SEPARATED FROM YOUR SPOUSE?                               
		DATE OF SEPARATION:_______________________
		WHERE DID YOU LAST COHABIT WITH YOUR SPOUSE? (Address)

CHILDREN BORN OF MARRIAGE OR LEGALLY ADOPTED:

			NAME				DATE OF BIRTH       SOC. SEC. NO.

	                                                                                                                                             

	                                                                                                                                             

	WHERE DO YOUR MINOR CHILDREN NOW RESIDE?____________________
	____________________________________________________________
	
	WHERE HAVE THEY RESIDED FOR THE LAST 5 YEARS? (if applicable)

	____________________________________________________________
	
	HAVE THERE BEEN ANY PREVIOUS CUSTODY PROCEEDINGS?                            
	____________________________________________________________
	
HUSBAND'S EMPLOYER:______________________________________________

	OCCUPATION/TITLE:________________________
	DATE PRESENT EMPLOYMENT COMMENCED:                                                   
	PREVIOUS EMPLOYER:__________________________________________
	GROSS ANNUAL INCOME: $__                                   _____________
	IF RETIRED MILITARY, BRANCH AND DATES OF SERVICE:___________
	____________________________________________________________
	OTHER INCOME (trusts, rental, partnerships, business, dividends, interest, etc.)

WIFE'S EMPLOYER:                                                                                                          

	OCCUPATION/TITLE:__                                                                                   
	DATE PRESENT EMPLOYMENT COMMENCED:___________________
	PREVIOUS EMPLOYER:                                                                                   
	GROSS ANNUAL INCOME: $_______________
	IF RETIRED MILITARY, BRANCH AND DATES OF SERVICE:___________
	____________________________________________________________
	OTHER INCOME (trusts, rental, partnerships, business, dividends, interest, etc.)
	____________________________________________________________

ASSETS:

	MARITAL RESIDENCE (Address):_________________________________
		COUNTY/CITY OF:                                                        
		MONTHLY RENT IF NOT OWNED:___                               ________
		(If not owned skip next 2 sections)
		DATE OF PURCHASE: MONTH                         YEAR                         
		PURCHASE PRICE: $___________________
		ESTIMATED CURRENT VALUE: $____________________
		MORTGAGE OR TRUST PAYMENT: $                           BALANCE: $________
		2ND MORTGAGE OR TRUST?     $                        BALANCE: $_                        

	PREVIOUS RESIDENCE OWNED PRIOR TO MARITAL HOME:
		DATE OF PURCHASE:                                   PRICE PAID: $                               
		DATE SOLD: _______________  SALES PRICE: $ __________________

	OTHER REAL ESTATE OWNED (Address):___________________________
		COUNTY/CITY OF: ______________________________
		DATE OF PURCHASE: MONTH ___________ YEAR ___________
		PURCHASE PRICE: $                                             
		ESTIMATED VALUE: $_                                           
		RENTAL INCOME: $____________________
		MORTGAGE OR TRUST PAYMENT: $ _________BALANCE: $                              
		2ND MORTGAGE OR TRUST? $ ______________BALANCE: $__________            

	CHECKING ACCOUNTS:
		BANK OR S&L:____________________________
		ACCOUNT TYPE:___________________________
		ACCOUNT BALANCE:   $                                      
		ACCOUNT OWNER(S): $                                        

		BANK OR S&L:                                                        
		ACCOUNT TYPE:                                                   
		ACCOUNT BALANCE:  $_                                      
		ACCOUNT OWNER(S): ____________________

	SAVINGS ACCOUNTS:
		BANK OR S&L:____________________________
		ACCOUNT TYPE:                                                    
		ACCOUNT BALANCE: $________________________
		ACCOUNT OWNER(S):_______________________

		BANK OR S&L:_                                                            
		ACCOUNT TYPE:_                                                         		
		ACCOUNT BALANCE: $_                                              
		ACCOUNT OWNER(S):                                                                                           

	MONEY MARKET FUNDS:_________________________________________
		AMOUNT: $                                                                                                              
		IN WHOSE NAME?                                                                                             
	
	CERTIFICATES OF DEPOSIT:____________________________________
		AMOUNT: $__________________
		IN WHOSE NAME?                                                                                        

	STOCKS/BONDS/MUTUAL FUNDS

		NAME OF SECURITY:______________________________________
		NO. OF SHARES:                             DATE PURCHASED:                                          
		IN WHOSE NAME? _                                                                                                    
		CURRENT VALUE: $_____________________
                                                                                      
		NO. OF SHARES________
		DATE PURCHASED__________________
		IN WHOSE NAME?                                                                               
		CURRENT VALUE: $_                                         
			(use back of this page if necessary)

	IRAs

		HUSBAND:  YES ___  NO ___
			VALUE: $                                       
			NAME OF BANK/FUND:                                                                                      
		WIFE:  YES ___  NO ___
			VALUE: $                                   
			NAME OF BANK/FUND:________________________________

	PENSIONS

		HUSBAND
			NAME OF PLAN:                                                                                                  
			TYPE OF PLAN:(military, 401K, etc.)_______________
			DATES OF PARTICIPATION: FROM :                             TO:                              			PLAN ADMINISTRATOR:_                                                                               

		WIFE
			NAME OF PLAN:                                                                                               
			TYPE OF PLAN:(military, 401K, etc.)_______________
			DATES OF PARTICIPATION: FROM__________TO__________
			PLAN ADMINISTRATOR:                                                                                  

	INHERITANCE

		HUSBAND:  YES ___  NO ___
			FROM WHOM? _______________________________________
			DATE: ___________________  VALUE: $_______________
			DESCRIPTION IF NOT CASH:__________________________
			WHERE IS IT NOW?__________________________________

		WIFE:  YES ___  NO ___
			FROM WHOM? _______________________________________
			DATE: ___________________  VALUE: $_______________
			DESCRIPTION IF NOT CASH:__________________________
			__________________________________________________
			WHERE IS IT NOW? _________________________________

	SAFE DEPOSIT BOX:
		LOCATION:______________________________________________
		BOX NO.:_____________
		PERSONS ON ACCESS CARD:________________________________
		CONTENTS: _____________________________________________
		_______________________________________________________
		_______________________________________________________
		_______________________________________________________

	MOTOR VEHICLES, BOATS, CYCLES, AIRPLANES, ETC.

		YEAR _____  MODEL______________________________________
		HOW TITLED:____________________________________________
		DRIVERS:_______________________________________________
		VALUE: $_______________    AMOUNT OWED $_______________
		MONTHLY PAYMENT: $_________________

		YEAR _____  MODEL______________________________________
		HOW TITLED:____________________________________________
		DRIVERS:_______________________________________________
		VALUE: $_______________    AMOUNT OWED $_______________
		MONTHLY PAYMENT: $_________________

		
		YEAR _____  MODEL______________________________________
		HOW TITLED:____________________________________________
		DRIVERS:_______________________________________________
		VALUE: $_______________    AMOUNT OWED $_______________
		MONTHLY PAYMENT: $_________________

	HOUSEHOLD FURNISHINGS & EFFECTS:

		ESTIMATED VALUE: $___________________
		ESTIMATED VALUE OF POSSESSIONS YOU BROUGHT INTO THE 				MARRIAGE: $__________________
		HAVE HOUSEHOLD FURNISHINGS OR PERSONAL EFFECTS BEEN
		DIVIDED? ___ YES   ___ NO

	OTHER ASSETS:

	FOR ANY INTEREST WHICH YOU OR YOUR SPOUSE MAY HAVE IN ANY 
	OTHER ASSET WITH VALUE IN EXCESS OF $500, LIST:

			ASSET			DATE ACQUIRED	  VALUE

		_________________________	________________	 ________
		_________________________	________________	 ________
		_________________________	________________	 ________
	
	PARTNERSHIPS

		ARE YOU IN ANY PARTNERSHIP(S)? YES ___  NO ___
		NAME OF PARTNERSHIP:___________________________________
		ARE YOU A GENERAL PARTNER         OR LIMITED PARTNER____ ?
		NATURE OF THE PARTNERSHIP OR WHAT IT OWNS:_____________
		_______________________________________________________
		ESTIMATED VALUE OF YOUR INTEREST: $_______________

		IS YOUR SPOUSE IN ANY PARTNERSHIP(S)? YES ___  NO ___
		NAME OF PARTNERSHIP:___________________________________
		ARE THEY A GENERAL PARTNER ___ OR LIMITED PARTNER ___ ?
		NATURE OF THE PARTNERSHIP OR WHAT IT OWNS:_____________
		ESTIMATED VALUE OF THEIR INTEREST: $_______________

	LIFE INSURANCE (for you or your spouse)

		INSURANCE COMPANY:_____________________________________
		NAME OF INSURED:_______________________________________
		NAME OF BENEFICIARY:___________________________________
		FACE AMOUNT: $_______________
		IS IT WHOLE LIFE ___ OR TERM ___ ?

		INSURANCE COMPANY:_____________________________________
		NAME OF INSURED:_______________________________________
		NAME OF BENEFICIARY:___________________________________
		FACE AMOUNT: $_______________
		IS IT WHOLE LIFE ___ OR TERM ___ ?

	MEDICAL INSURANCE

		HUSBAND
			COMPANY:__________________________________________
			PERSONS COVERED:__________________________________
		
		WIFE
			COMPANY:__________________________________________
			PERSONS COVERED:__________________________________

	TRUSTS

		ARE YOU THE BENEFICIARY OF A TRUST? YES ___  NO ___
		WHAT IS THE NAME OF THE TRUST?_________________________
		NAME OF TRUSTEE:_______________________________________
		WHAT INCOME RIGHTS DO YOU HAVE?________________________
		WHAT RIGHTS TO PRINCIPAL DO YOU HAVE?__________________

		IS YOUR SPOUSE THE BEN'Y OF A TRUST? YES ___  NO ___
		WHAT IS THE NAME OF THE TRUST?_________________________
		NAME OF TRUSTEE:_______________________________________
		WHAT INCOME RIGHTS DO THEY HAVE?_______________________
		WHAT RIGHTS TO PRINCIPAL DO THEY HAVE?_________________

DEBTS (Creditors, education loans, etc.)

LENDER, CREDIT		 PURPOSE       HUSBAND     MONTHLY       BALANCE
CARD COMPANY OR BANK       OF LOAN         OR WIFE       PAYMENT        OWING

__________________________  	 _____________
__________________________      ___________       H  W  Jt         $______          $______
__________________________      ___________       H  W  Jt         $______          $______
____
__________________________      ___________       H  W  Jt         $_____            $______
__________________________      ___________       H  W  Jt         $______          $______
__________________________  	 ________________
__________________________      ___________       H  W  Jt         $______          $______
__________________________      ___________       H  W  Jt         $______          $______
__________________________  	 ___________