Family Questionnaire - Irama Valdes, P.A.

1. INFORMATION ABOUT CLIENT:

Name

Address

Telephone (no dashes)

Email Address

Occupation

Average Monthly Gross Income (before taxes and payroll deductions are taken out; income includes bonuses and commissions)

2. INFORMATION ABOUT SPOUSE

Name

Address

Telephone (no dashes)

Email Address

Occupation

Average Monthly Gross Income (before taxes and payroll deductions are taken out; income includes bonuses and commissions), if known.

Do they already have counsel?
Yes No

Please List Counsel’s Information

3. INFORMATION ON MARRIAGE/RELATIONSHIP

Are you currently married?
Yes No

If so, when were you married?

In what state and county were you married?

If married, are you currently living apart from your spouse?
Yes No

If so, what date did you begin living separate and apart from your spouse (date of separation)?

4. DO YOU HAVE CHILDREN FROM THIS RELATIONSHIP? If yes:

Name

Date of Birth

Where are they residing?

Are they in daycare?
Yes No

If so, how much is the tuition per week?

Who pays the tuition?

If living apart, briefly describe who has custody of the child(ren) and the visitation schedule:

5. ASSETS (include fair market value)

Real Property
In the spaces below, please add the following information for each Real Property.

i. Address, Name on Title, and How title is held (this will usually be one of the following: husband and wife, joint tenants, joint tenants with rights of survivorship, life estate)

ii. Address, Name on Title, and How title is held (this will usually be one of the following: husband and wife, joint tenants, joint tenants with rights of survivorship, life estate)

iii. Address, Name on Title, and How title is held (this will usually be one of the following: husband and wife, joint tenants, joint tenants with rights of survivorship, life estate)

Vehicles, Motorcycles, Water Vessel
In the spaces below, please add the following information for each Vehicle, Motorcycle and Water Vessel.

i. Year, Make, Model

ii. Year, Make, Model

iii. Year, Make, Model

Stocks
In the spaces below, please add the following information for Stocks.

i. Stocks

ii. Stocks

iii. Stocks

Bank Accounts
In the spaces below, please add the following information for Bank Accounts; for each account.

i. Name of Bank Account, Amount in account, if known

ii. Name of Bank Account, Amount in account, if known

iii. Name of Bank Account, Amount in account, if known

Life Insurance Policy
In the spaces below, please add the following information for Life Insurance Policy.

i. Life Insurance Policy

ii. Life Insurance Policy

iii. Life Insurance Policy

Retirement Accounts (IRA, 401K, Other Retirement or Pension Accounts)
In the spaces below, please add the following information for Retirement Accounts.

i. Retirement Accounts

ii. Retirement Accounts

iii. Retirement Accounts

Businesses
In the spaces below, please add the following information for Businesses.

i. Businesses

ii. Businesses

iii. Businesses

6. DEBTS (include amount of debt)

Mortgages (include property address the mortgage is associated with)

Line of Equity

Credit Cards

Personal Loans

8. Have you and your spouse / partner made any agreements (as to custody, child support, division of assets, payment of bills, etc)?

Yes No

If so, please briefly explain:

HOW DID YOU HEAR ABOUT US?