William r. Valent
attorney at law
6500 SW MacAdam
Suite 300Phone: (503) 245-1211
Portland OR 97239Fax: (503) 245-2117
MODIFICATION ISSUES
HUSBAND:
Full Name:______
FirstMiddleLast
Address:______
Street\NumberCity CountyState Zip Code
Phone:______
HomeWorkCell
E-Mail:______
Social Security Number:______
Driver’s License Info:______
NumberIssuing State
Date of Birth:______
MonthDayYear
Birth Place:______
Name of State or Foreign Country
Number of Prior Marriages:______How most-recent marriage ended: ______
(Divorce, Death, or Separation)
Highest Level of Education
Race:______Completed: ______
(List highest level only, such as grade in high school, number of years in college, or 5+ if advanced degree)
WIFE:
Full Name:______
FirstMiddleLast
Maiden Name:______
Prior Legal Names
Used by Wife:______
(Generally these will be prior married names)
Address:______
Street\NumberCity CountyState Zip Code
Phone:______
HomeWorkCell
E-Mail:______
Social Security Number:______
Driver’s License Info:______
Number Issuing State
Date of Birth:______
MonthDayYear
Birth Place:______
Name of State or Foreign Country
Number of Prior Marriages:______How most-recent marriage ended: ______
(Divorce, Death, or Separation)
Highest Level of Education
Race:______Completed: ______
(List highest level only, such as grade in high school, number of years in college, or 5+ if advanced degree)
RELATIONSHIP INFORMATION:
Place Of This Marriage:______
CityCountyState
Date Of This Marriage:______
MonthDayYear
Date Parties Last
Lived Together:______
MonthDayYear
Live Together
Before Marriage:No: ______Yes: ______If Yes, how long: ______
Parties Have A
Pre-nuptial Agreement:Yes: ______No: ______
CHILDREN OF
THIS MARRIAGE:______
Oldest Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
HUSBAND’S “OTHER”
CHILDREN:______
Oldest Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
Who has custody of
these children?Husband: ______Children’s Mother: ______
Child Support:______
Who is ordered to pay child support to the other (Husband or Children’s Mother)?
Amount of Support:______Support Current:______
(Yes or No)
WIFE’S “OTHER”
CHILDREN:______
Oldest Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
______
Next Child’s Full NameMonth, Day, and Year of Birth SSN
Who has custody of
these children?Wife: ______Children’s Father: ______
Child Support:______
Who is ordered to pay child support to the other (Wife or Children’s Father)?
Amount of Support:______Support Current:______
(Yes or No)
Please provide the following information for the past five years for the children you have together:
Name(s) of Child(ren) / Residing with which parent? (one or both) / Dates (from/to) / Place (city/state)