Domestic Questionnaire | Benton Family Law

Our Domestic Questionnaire is mandatory for all of our services. The Domestic Questionnaire simply gathers information that we use to determine what services you are interested in, and some personal information about you, so that we can better determine your situation. It should take no longer than 15-20 minutes to complete.

Client Name

First
Middle
Maiden
Last

Address

Address 1
Address 2

City

State

Postal Code

Personal Information

Date of Birth

County of Birth

State of Birth

Driver’s License No.

Date of Marriage

Clients Previous Marriages:

Yes

If yes, please set fourth below:

Name of Spouse

Marriage Ended By:	Death	Divorce
Date of Dissolution:

Your Education
Highest Grade Completed

Your Employer
Employer’s Address

Your Position
Your Salary
Medical Insurance

Who is covered under the policy?

Benefits such as bonuses, retirement, medical, etc.

Income from other sources – Please list the source and amount.

Please Note

ATTACH A COPY OF YOUR LAST THREE YEARS PERSONAL TAX RETURNS.
ATTACH A COPY OF ALL FINANCIAL STATEMENTS OR CREDIT APPLICATIONS GIVEN WITHIN THE LAST THREE YEARS BY YOU AND YOUR SPOUSE.

Spouse’s Name

First
Middle
Maiden
Last
Suffix

Address

Address 1
Address 2

City
State

North CarolinaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

American SamoaDistrict of ColumbiaFederal States of MicronesiaGuamNorth MarianasPuerto RicoU.S. Virgin Islands

Postal Code

Date of Birth


County of Birth	State of Birth
Spouse’s Education
Highest Grade Completed
Spouse’s Previous Marriages:	Yes	No

If yes, please set fourth below:

Name of Spouse

Marriage Ended By:	Death	Divorce
Date of Dissolution:

Spouse’s Employer
Employer’s Address

Spouse’s Position
Spouse’s Salary
Medical Insurance

Who is covered under the policy?

Benefits such as bonuses, retirement, medical, etc.

Income from other sources – Please list the source and amount.

Children

Children Born or Adopted of the Marriage:

Name

Date of Birth

Resides With

Name

Date of Birth

Resides With

Name of Daycare Facility

Address

Telephone

Cost Per Week of Day Care

Person You Deal With at Day Care

Pensions

No. 1

In the Name of
Name of Company
Address of Company
Account Number
Type

Download Our Pension Data Release Form

Medical Insurance Information of Client and Spouse

Client

Name of Insurance Company

Address of Company

Policy Number

Type of Coverage

Amount of Premium

Time Period Your Premium Covers

Amount of Deductable

Names of those Covered Under the Policy

Spouse

Name of Insurance Company

Address of Company

Policy Number

Type of Coverage

Amount of Premium

Time Period Your Premium Covers

Amount of Deductable

Names of those Covered Under the Policy

Were you referred to this office?

Yes

If so, by whom?

The reason for retaining this office is in regard to rights to:

Explain what information and assistance you hope to receive.

My priorities are as follows:

Please list and rank these priorities and if there are others, add them to the list also.

	Separation
	Child Custody
	Child Support
	Alimony
	Divorce
	Possession of Property
	Motor Vehicles
	House
	Furniture
	Property Settlement
	Other

What immediate needs do you need for Benton Family Law to accomplish as your attorney?

Is there something that you which might make your spouse want to settle this case very quickly, and if so, what is that information?

When you complete this questionnaire, please submit it below, and bring the following items into our offices:

Statements, tax returns, financial statements, deeds, deeds of trust, and any other documents requested at the bottom of the preceding pages.
Twenty to thirty pages of history of your marriage.
The names and addresses of twelve witnesses who could benefit your case. A Witness Trial Checklist Form is available at the bottom of this page. Please use one for each witness.
The names and addresses of all possible witnesses your spouse may subpoena and what they may say to hurt your case.
Write five pages on what your spouse will say bad about you.
Your daily schedule on a weekly basis, that is, an hour by hour explanation of your home and work schedule.
Are there facts which your spouse does not know about which are harmful to your case? What are they?
A picture of yourself, your spouse, and your children.

Other Notes:

Domestic QuestionnaireRequired Information

Client Name

Address

Personal Information

If yes, please set fourth below:

Please Note

Spouse’s Name

Address

If yes, please set fourth below:

Children

Children Born or Adopted of the Marriage:

Pensions

No. 1

Client

Spouse

If so, by whom?

When you complete this questionnaire, please submit it below, and bring the following items into our offices:

Services

Forms