FORT IRWIN LEGAL ASSISTANCE DIVISION
DIVORCE QUESTIONAIRE
rev. 09/05/2014
Privacy Act Statement
Authority: 10 USC 3012
Principal Purposes: To screen clients for eligibility for legal assistance services; to gather personal information in order to determine if conflicts of interests exist.
Routine Uses: None.
Disclosure is Voluntary, but failure to supply this information may preclude the provision of legal services. Completing this form, in and of itself, does not establish an attorney / client relationship.
ð NEW DIVORCE ÿ LEGAL SEPARATION ÿ EXISTING CASE
GENERAL INFORMATION
(1) YOUR FULL NAME: ______Last 4 SSN ______
FIRST MIDDLE LAST
(2) Home Ph: ______Work Ph ______Cell Ph ______Email ______
(3) Address: ______City ______State ______Zip ______
(4) Military Member Y__ N__ Military Unit: ______ð Active Duty ð National Guard ð Reserve
(5) YOUR SPOUSE'S FULL NAME: ______Last 4 SSN ______
FIRST MIDDLE LAST
(6) Home Ph: ______Work Ph ______Cell Ph ______Email ______
(7) Address: ______City ______State ______Zip ______
(8) Military Member Y__ N__ Military Unit: ______ð Active Duty ð National Guard ð Reserve
(9) Are you or your spouse planning to move, PCS, or ETS within the next 12 months? ð YES ð NO
If yes, When ______Where______
(10) Primary issue of divorce today: ð Divorce Information (State_____) ð File for divorce/legal separation (State_____)
ð Respond to a filed divorce (State_____) ð Issue with Existing Divorce (State_____)
(11) Have you (ð YES ð NO) or your spouse (ð YES ð NO) retained a civilian attorney to represent you for this divorce?
(12) Is there anything urgent or time sensitive related to your case? Has a court given you a deadline to complete anything or told you to be anywhere on a certain date or time? ______
______
MARRIAGE INFORMATION
(as applicable)
(13) Date Of Marriage: ______/______/______State of Marriage: ______
Date Of Separation: ______/______/______Date Of Divorce: ______/______/______
Date Arrived to California: ______/______/______
(14) Have you or your spouse already filed for Divorce, Legal Separation or Annulment?
ð YES ð NO If yes, Who ______When ______Where______
Interviewer Notes: ______
______
______
______
______
STOP HERE FOR EXISTING DIVORCE CASES. CONTINUE FOR NEW DIVORCE AND LEGAL SEPARATION
FORT IRWIN LEGAL ASSISTANCE DIVISION
DIVORCE QUESTIONAIRE
rev. 09/05/2014
(15) Does your spouse agree to divorce? ð YES ð NO
(16) Do you and your spouse agree on custody of children and division of property? ð YES ð NO
RESIDENCY
(17) Have you (ð YES ð NO) or your spouse (ð YES ð NO) lived in San Bernardino County, California for the past 6 months?
(18) In which state do you claim legal residency? ______Do you file taxes in this state? Yes__ No__
(19) Do you and your spouse intend to physically separate (if applicable)? Yes__ No__ N/A __ If so, when? ______
MINOR CHILDREN OF MARRIAGE
(do not list step-children, unless they have been adopted)
ð Check here if Wife is currently pregnant
ð Check here if there are NO MINOR CHILDREN
(20) Name Living With
______ð You ð Spouse ð Other: ______
______ð You ð Spouse ð Other: ______
______ð You ð Spouse ð Other: ______
______ð You ð Spouse ð Other: ______
______ð You ð Spouse ð Other: ______
(21) Have your children lived in San Bernardino County, California for the past 6 months? ð YES ð NO
(22) Are there any custody or guardianship Orders covering any of the children? ð YES ð NO
(23) Is there a pre-existing Child Support or Spousal Support Order? ð YES ð NO
Interviewer Notes:______
______
______
______
______
______
______
______
______
______
______
______
Interviewer’s Name ______
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