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About Us
Our Team
Location
Success Examples
FAQ
Services
Annulments
Child Custody & Visitation
Child Support
Divorce & Domestic Partnership Dissolution
Domestic Violence Restraining Orders
Legal Separation
Mediation
Paternity / Parentage
Post Judgment Issues
Prenuptial Agreements
Property Division
Spousal Support
Step Parent Adoption
Info Center
Contact Us
Make a Payment
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Client Information Form – Divorce Mediation with Children
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Client Information Form – Divorce Mediation with Children
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This form is only to be used by potential clients of Mesnik Law Group. Please fill this form out as completely as possible. Note, all data entered in this form will be kept strictly confidential if (and only if) you are a potential client of Mesnik Law Group, Inc.
Client's Full Legal Name
*
Other Names/Aliases
Date of Birth
*
MM slash DD slash YYYY
Addresses
Home Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Information
Cell/Mobile Phone
*
Home Phone
Work Phone
Personal Email
*
Only include if you approve for us to use
Work Email
Only include if you approve for us to use
Employment
Current Employer Name
*
Please indicate N/A if unemployed
Position
Date Started Current Job
MM slash DD slash YYYY
Approximate if needed
Hours Work Per Week
Gross Monthly Income
*
Before Taxes (put zero if unemployed)
Avg Bonus, Profit Sharing
Monthly average
Housing, BAH, BAS
Monthly
Personal Information
Social Security Number
Drivers License / State
Military Service
*
Never
Active
Retired
Statistical Information
Date of Marriage
*
MM slash DD slash YYYY
Date of Separation
MM slash DD slash YYYY
Maiden Name
Restore Maiden Name
Yes
No
Unsure
Not Applicable
Where Married
*
(City, State, Country if Not USA)
Previous Marriages
*
(How Many)
Children of Oher Relationships
*
(How Many)
Do You Have a Pre or Post Nuptial Agreement
*
Yes
No
Children's Information
Oldest Child's Full Name
*
Gender
*
Male
Female
Other
Date of Birth
*
MM slash DD slash YYYY
Place of Birth
*
City & State
2nd Oldest Child's Full Name
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Place of Birth
City & State
3rd Oldest Child's Full Name
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Place of Birth
City & State
4th Oldest Child's Full Name
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Place of Birth
City & State
More Children
Children's Residence
Children's Current Address
*
Date Lived From
*
MM slash DD slash YYYY
Date Lived To
*
Who lived With / Relationship to Child[ren]
*
Past Address within Last 5 Years
Date Lived From
MM slash DD slash YYYY
Date Lived To
MM slash DD slash YYYY
Who lived With / Relationship to Child[ren]
Past Address within Last 5 Years
Date Lived From
MM slash DD slash YYYY
Date Lived To
MM slash DD slash YYYY
Who lived With / Relationship to Child[ren]
Past Address within Last 5 Years
Date Lived From
MM slash DD slash YYYY
Date Lived To
MM slash DD slash YYYY
Who lived With / Relationship to Child[ren]
Check here if more addresses
Assets & Debts
Real Property
Real Property Address
(Homes, Land, Commercial)
Current Value
(approximate is okay)
Mortgage Principal
(approximate is okay)
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Real Property Address
(Homes, Land, Commercial)
Current Value
(approximate is okay)
Mortgage Principal
(approximate is okay)
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Real Property Address
(Homes, Land, Commercial)
Current Value
(approximate is okay)
Mortgage Principal
(approximate is okay)
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Check here if there are more properties:
Yes
Vehicles
Vehicle/Boat/RV
(Homes, Land, Commercial)
Current Value
(approximate is okay)
Loans
(approximate is okay)
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Vehicle/Boat/RV
(Homes, Land, Commercial)
Current Value
(approximate is okay)
Loans
(approximate is okay)
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Vehicle/Boat/RV
(Homes, Land, Commercial)
Current Value
(approximate is okay)
Loans
(approximate is okay)
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Check here if there are more vehicles:
Yes
Bank Accounts, Retirements, Savings, Investments
Account Name and Type
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Account Name and Type
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Account Name and Type
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Account Name and Type
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Account Name and Type
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Check here if there are more accounts:
Yes
Debts
Debt Name and Type
ie Credit Card, Personal Loan, etc.
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Debt Name and Type
ie Credit Card, Personal Loan, etc.
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Debt Name and Type
ie Credit Card, Personal Loan, etc.
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Debt Name and Type
ie Credit Card, Personal Loan, etc.
Current Balance
(approximate is okay)
Account Owner
Date Acquired
MM slash DD slash YYYY
(approximate is okay)
Check here if there are more debts:
Yes
