1. Name and Contact Information
State your full name, current residence, telephone number, social security number, and date of birth; any names by which you have been known in the past; and, for any other person residing in your household, the full name, current residence, telephone number, social security number, date of birth, and any names by which that person has been known in the past.
2. Education and Training
Please provide the extent of your education, course of study, degrees obtained, and when obtained.
A. State the name and address of each employer you have had during the last three years, and list your job title at each such employment. If you have been self-employed at any time during those three years, so state and give months and years.
B. State the gross monthly income from each employer or source of income named in Paragraph A.
C. State the monthly net take home from your current employment.
D. Have you engaged in any part-time employment in addition to your regular occupation within the past three years? (Y/N) _____. If so, please state whether you are still engaged in this part-time employment and state your monthly income from this employment.
E. Have you received overtime pay, commissions or bonuses within the last three years? (Y/N) _____. If yes, please state below the monthly gross amount you have earned from overtime pay and the dollar amount of each commission and/or bonus received.
F. Attach your twelve most recent payroll stubs and your contract of employment.
4. Deferred Compensation and Retirement Benefits
Are you or have you ever been a participant in a retirement plan (such as a pension, deferred compensation, profit-sharing, stock, investment, thrift savings, § 401(K), OR military retirement plan) hereinafter referred to as “plan” or are you or have you ever received disability pay? (Y/N) _____. If yes:
A. Describe the nature of each plan.
B. Indicate whether each plan is qualified with the IRS.
C. State the name of the plan and the name and address of the trustee and the plan administrator.
D. State the date you began the employment that permitted you to participate in the plan and the number of years and months in which you have participated and are entitled to credit.
E. State the value of your interest as of the last valuation date and state that date.
F. Attach a copy of your current plan and your most recent plan statement.
G. State whether there is a survivor benefit available on the plan. If so, state who is named the survivor of the plan.
5. Health Insurance
A. Do you have health insurance through your present employer? (Y/N) _____. If so, indicate what conversion benefits are available to your spouse at the time of the dissolution of marriage, and indicate the persons presently covered and the cost for dependent coverage, if any. Attach a copy of your current health plan.
B. Provide documentation from your employer that sets forth the following:
1. Cost to insure yourself only, if there is a cost;
2. Cost to insure your spouse; and
3. Cost to insure your child or children.
6. Other Income
Do you have any sources of income other than as described in Interrogatory No. 3? (Y/N) ______. If so, state each source of income and the amount received from each source in this year and in each of the last 3 calendar years. Attach a copy of each document showing each additional source of income.
7. Life Insurance
Do you presently own or have an interest in any life insurance or annuity policy? (Y/N) ______.If so, for each policy, please state:
A. The name and address of the insurance company.
B. The type of policy, i.e., term, straight life, universal, whole life, tax deferred annuity or other.
C. Whether that insurance is connected with your employment.
D. The amount and date of each loan taken on the policy.
E. The present cash surrender value of the policy, if any.
F. Cost to you, if any, on an annual basis.
G. The name of each beneficiary.
H. Attach a copy of each insurance policy.
I. Attach a copy of any beneficiary designation change made by you within the last 12 months.
8. Employment Benefits
Do you receive or do you expect to receive or have you received in the past calendar year, any employment related benefits, such as a vehicle or vehicle allowance, stock options, pension or profit- sharing payments, vacation pay or expense account payments or reimbursements? (Y/N) _____.If so, specify the benefits you receive or received.
9. Child Legal Decision-Making
A. Do you believe that you and your spouse can reach an agreement concerning legal decision- making and parenting time without the intervention of the court or conciliation services?
B. How do you want to share parenting time between parents?
1. How do you want to divide the week?
2. How do you want to divide holidays?
3. How do you want to divide summer or other school recesses?
C. How do you propose making the following decisions regarding your child(ren)?
1. Physical/Medical matters.
2. Psychological/Psychiatric matters.
3. Legal matters.
4. Religious matters.
5. Educational matters.
6. Activities and/or sports.
D. Is there a child of the marital relationship with special needs, disabilities, psychological, psychiatric or other developmental handicaps? (Y/N) ______.
1. What are the child’s special needs?
2. What are the extraordinary expenses associated with caring for this child?
3. Is this child over the age of 18?
E. What, if any, concerns do you have about the other parent’s parenting skills?
F. For each answer you provided above, list each and every fact supporting your position.
10. Child Protective Services
Have you or has any person residing in your household ever been investigated by any agency in any state for any reason related to abuse or neglect of children? (Y/N) _____. If yes, identify the following:
A. State and agency investigating;
B. Date of investigation;
C. Reason for investigation, and
11. Personal Limitations
Do you have any mental or physical limitations that would affect your ability to care for your minor child/children? If yes, identify the limitations in detail.
12. Driving History
A. Has any jurisdiction ever revoked or suspended your driver’s license or placed you on probation? If yes, please explain and give information regarding the following:
2. Approximate date; and
3. The reason for the revocation, suspension, or probation.
B. Have you had any moving violations in the last 3 years? If yes, identify the following:
2. Approximate date; and
3. Moving violations.
13. Employment History
Have you ever been the subject of disciplinary complaints at any place of employment? If yes, discuss the situation.
14. Criminal History
Have you or has any person residing in your household ever been investigated or arrested for any criminal behavior? (Y/N) _____. If yes, identify the following:
B. Approximate date; and
C. The alleged criminal behavior.
15. Domestic Violence
A. Have you, your spouse, or any person residing in your household been a party to any litigation, in any court of this state or any other state in the United States, which relates to domestic violence?
B. If so, please provide the location of the court where the action was filed; the nature of the complaint; the disposition thereof; and the expiration date of any resultant order.
C. Have you, your spouse, or any person residing in your household been subject to an order of any court of this state or any other state in the United States which limits or prohibits conduct or actions because of violence or physical abuse?
D. Have there ever been allegations of child abuse, neglect, abandonment or incorrigibility filed against you, your spouse, or any person residing in your household through child protective services or a similar agency any law enforcement agency or any juvenile courts in any state of the United States?
E. Please provide sufficient details regarding disposition of said allegations or investigation, including specific dates, names of investigators and other persons involved.
F. Have you, your spouse, or any person residing in your household ever been arrested or investigated by a law enforcement agency regarding domestic violence? If so, state when, where, by what agency and the nature of the investigation.
16. Residence and Real Estate
Please complete the attached Real Estate Chart for each piece of real estate in which you have an interest.
17. Sole and Separate Property
Do you own any property that you believe is your sole and separate property? (Y/N) ______. If yes, please:
A. Describe the property;
B. State the present location of the property;
C. State the value of your interest in the property on the date of marriage;
D. State the facts that support your belief that it is sole and separate property; and
E. Identify and attach every document in your legal decision-making, possession or control which supports your claim that the property is separate property.
F. State whether you have used any community funds to improve, protect, pay for or maintain the separate property? _____. If so, identify dates, source and amounts of funds expended and identify any documents that show the expenditures.
18. Financial Institutions
A. If you have had funds in any financial institution account this year or within the past 3 years, please complete the attached Financial Institution Accounts Chart.
B. Do you have any money on deposit in any account, in any name other than your own? _____. If so, for each account, please state:
1. Where the account is maintained; and
2. The name under which the account is maintained.
C. Within the past 12 months, have you transferred any assets to a third party or parties or institution, to be held for your benefit? ______.
If so, for each account, please state:
1. Where the account is maintained; and
2. The name under which the account is maintained.
D. Attach financial institution statements and a copy of each check register for each account in which you have had funds or to which you have transferred funds to be held for your benefit for the past 12 months.
19. Safe Deposit Boxes
A. Within the last 3 years, have you had access to any safe deposit box, safe or vault or other place of safekeeping (hereinafter “depository”)? (Y/N) ______. If so, for each depository, please state the name of the financial institution or branch or other location where the depository is located.
B. State whether each depository is open or closed as of the date of your answers to these interrogatories.
C. List present contents of each depository and identify any items removed within the last 3 years.
20. Business Entities: Corporations, Partnerships, & Sole Proprietorships
A. Identify every business entity (hereinafter “business”) in which you have any interest, whether equitable or legal, and identify the type of business (corporation, general partnership, limited partnership, joint venture, sole proprietorship).
B. With respect to each business listed, describe the type of records maintained in the last 5 years; e.g., general ledger, general journal, cash disbursements journal, etc.
C. Indicate the name, address, telephone number, and employee title of each individual or business that has possession, legal decision-making or control of the records above described.
D. Provide the name, address and telephone number of each individual or business that has possession, legal decision-making or control of the tax returns for each business listed for the last 3 years.
E. Provide the current “net worth” of each business listed and the date that “net worth” was derived. “Net worth” means total assets minus total liabilities. If you have an opinion, please provide the fair market value of the business as of this date.
F. With respect to each business listed, indicate your and your spouse’s interest in the business and the name and address of every other person or entity(ies) having an interest in any such business you have listed.
G. Attach a copy of the most recent federal tax return filed for each business listed.
During the last 3 years have either you or your spouse suffered an injury for which you believe you may receive compensation or have you been a party to any lawsuit? (Y/N) _____. If so, please give details below.
22. Tax Returns
Did you file federal and state income tax returns for the last 5 tax years? If so, state as to each tax year,
A. Whether it was a joint or separate return.
B. Who currently has a copy of that return?
C. Who prepared the return?
D. Attach a copy of your 5 most recent personal federal and state tax returns with all relevant schedules, including all W-2 forms and 1099 forms.
23. Financial Statements
Has any financial statement, loan application, and/or credit application been prepared for you or by you or for any business entity listed in your answer to Interrogatory No. _____ within the past 3 years. If so, please state:
A. The name and address of each person, firm, corporation, partnership, mercantile or trade agency, or other organization to whom they were issued.
B. The date of each financial statement(s), loan application(s) and/or credit application(s).
C. Attach a copy of each financial statement or application.
24. Attorney’s Fees and Costs
State the terms and conditions of the employment of your attorney in this case, including the hourly rate or other basis for fees. Give full details of any agreement or understanding between you and your attorney in this case concerning fees and expenses, including information and specific amounts of any payments made to your attorney, the method of payment(s) and the source of the payment(s) in connection with this case. Attach the retainer agreement memorializing the employment of your attorney.
25. Witnesses and Exhibits
A. Do you intend to offer in evidence at the time of trial of this case any documents? (Y/N) ____. If yes, please state in complete detail:
1. The description, subject matter, form, name and number of each and every document;
2. The relevancy, in your opinion, of each and every document to the issues before the court.
B. Unless already disclosed pursuant to Rule 53 or 85 of these rules, list each witness you intend to call at the trial of this case, and as to each such person:
1. State that person’s name, address, telephone number and the relevance of the expected testimony to the case;
2. Give the nature and substance of each such person’s expected testimony.
C. Have you employed or do you intend to employ any expert witness for purposes of supporting any of your allegations in this litigation and/or for purposes of testifying at the trial of this action? ______. If so, unless already disclosed pursuant to Rule 53 or 85 of these rules, please state, for each such technician or expert, the following:
1. The expert’s name, or other means of identification, last known complete address and telephone number;
2. The expert’s profession, job title, or occupation and the field in which that person is an expert;
3. Whether you intend to call the expert as a witness during the trial of this action;
4. At what address the expert is presently employed;
5. Attach a copy of each expert’s resume or curriculum vitae.
26. Spousal Affidavits and Inventories
If there are minor children common to the parties, please complete Form 2, Child Support Affidavit.
If either party is asking for spousal maintenance, attorneys’ fees or costs, or for temporary orders to exclude a party from a residence, to divide community property or to order payment of debt, expenses or attorneys’ fees, please complete Form 3 (Comprehensive Affidavit).
Please complete the attached inventory of securities and personal property, including vehicles, having a value greater than $100.00, owned by you.