Client Intake Form – Part I Basic Information

 

  • Is Mediation Right For You?  We encourage you to ask your self these two questions.
    First, can I work with my spouse cooperatively, with the assistance of a mediator, and negotiate an agreement and save the costly expenses of contested divorce litigation? 
    Second
    , has my contested divorce litigation stalled or gone out of control and can I work with my spouse cooperatively with the assistance of a mediator.  If you answered yes to either of these questions it may be time to mediate your divorce and negotiate an agreement directly with your spouse and save the ongoing costly expenses of contested divorce litigation!
  • Notice:  At the Initial Free Consultation You, Your Spouse and the Mediator will complete and submit the below Intake form together.  Your mediator, within 24 hours of that initial consultation, will then prepare a Complementary beginning draft of you mediated agreement.  If you decide to retain us as your mediator we will continue adding onto that agreement until it is complete.  If you choose not to retain us, keep the beginning draft on us and use it as you like.

Client Intake Form - Part I Basic Information

Security


Today's Date:

Email of person completing this form (required)

Marriage

Date of the Parties Marriage:
City/Town/Village where Parties Marriage
State of the Parties Marriage
Type of ceremony

Children

Number of Children of the Marriage including adopted children
NoneOneTwoThreeFourFive




























































Wife's Information:

Wife''s Email (required):

Wife's Name:




Wife's Address1:

Wife's Address2:

Wife's City:

Wife's State:

Wife's Zip Code:

Wife's County:

Wife's Phone:

Wifes Date of Birth:

Wifes Place of Birth:

Wife's Social Security Number:

Husband's Information:

Husband's Email (required)

Husband's Name



Husband's Address1

Husband's Address2

Husband's City

Husband's State

Husband's Zip Code

Husband's County

Husband's Phone

Husbands's Date of Birth:

Husband's Place of Birth

Husband's Social Security Number

Fee Arangements

Type of Divorce Mediation Interested In - On-Line $1,250.00 or In Office $1,650.00.
On-Line$In-Office
Discount, if any.
1,800.00$1,500.00$1,250.00$900.00

NON-INTERFERENCE

SEPARATE OWNERSHIP

MARITAL DEBT

DISCHARGE AND RELEASE

MUTUAL RELEASE AND DISCHARGE OF CLAIMS IN ESTATES

ACKNOWLEDGMENT OF LEGAL RIGHTS PURSUANT TO SECTION 236(B) OF THE DOMESTIC RELATIONS LAW

(A)  APPLICABLE LAW.


 
(B)  CHILD SUPPORT AND MAINTENANCE. 

  1. income and property of the parties;
  2. duration of the marriage prior to physical separation;
  3. age and health of the parties;
  4. the capacity of the persons need to be self-supporting
  5. standard of living
  6. tax consequences of any amounts of money or property exchanges, given or received
  7. number of unemancipated child(ren);
  8. financial resources of the parties;
  9. physical and emotional health of the child(ren)
  10. all of the needs of the child(ren)
  11. non-monetary contributions;
  12. all of the factors reasonable and proper affecting the dissolution of the marriage and the amounts of money paid and/or exchange or given in this action and/or Agreement.

(C)  MARITAL PROPERTY. 

  1. property acquired by each party prior to the marriage;
  2. property acquired by each party by bequest;
  3. property acquired as a result of compensation for personal injury;
  4. the increase in the value of the separate property (non-marital)  except to the extent due to the contributions and efforts of the other spouse; and property acquired after the date of physical Separation of the parties.

 

The parties additionally acknowledge to each other that all property considered separate property and/or marital property as designated in the within agreement shall be deemed conclusively to be the sole and separate property of the designated spouse or the marital property of the spouse in whose name the property is currently held.

(D) DISTRIBUTION OF PROPERTY.

  1. income and property at the time of the marriage;
  2. income and property at the time of the commencement of the action and/or negotiation of the agreement;
  3. duration of the marriage and the date of physical separation of the parties;
  4. age and health of the parties;
  5. the needs of the custodial parent with regard to the marital residence;
  6. loss of inheritance and pension rights;
  7. award of maintenance, child support and/or family allowance;
  8. acquisition of property by indirect contributions, direct contributions, joint efforts, contributions as a spouse, contributions as a homemaker, and contributions to the career or career potential of the spouse;
  9. the liquid and/or non-liquid character of the marital property;
  10. probably future financial circumstances of the parties;
  11. the difficulty in the evaluation of business assets;
  12. all of the factors reasonable and proper affecting the dissolution of the marriage and the amounts of money paid and/or property exchanges or given in this action and/or Agreement.

The parties acknowledge that each is fully aware of the financial circumstances of his or her spouse and acknowledge that they are aware that each is entitled to full and complete disclosure of the financial circumstances of the other.  The parties specifically agree that no further financial disclosure is necessary and agree that there be no financial disclosure beyond that which has already been obtained by each of them.

DIVORCE

EXECUTION OF DOCUMENTS

VOLUNTARY EXECUTION OF AGREEMENT

MODIFICATION OR WAIVER

ENTIRE UNDERSTANDING

POSSIBLE INVALIDITY

GOVERNING LAWS

BINDING ON REPRESENTATIVES

INDEPENDENT COVENANTS

ENTIRE UNDERSTANDING