Hunt Law Firm - The Lake Charles, Louisiana DWI, Bankruptcy and Injury Attorney

Domestic Intake Form

DISCLAIMER: Submitting this form does not create an attorney/client relationship

Your Personal Information

Full Name:

Maiden Name:

Would you like to resume your maiden name?

Current Physical Address:

	Apartment #

City:

	State:		Zip Code:

County/Parish:

	If Other:

If Calcasieu, then how long have you lived in the Parish?

Phone Number:

	Work Phone Number:

Cell Phone Number:

	Alternate Phone Number:

Does your cell phone accept text messages?

If so, who is your cell phone provider?

Email Address:

Sex:

	Race		SSN: XXX - XX - :

Date of Birth:

Place of Birth City:

	State:

Number of marriages including this one?

Your Educational History and Employment

Level of Education:

Place of Employment:

Street Address:

	Suite Number:

City:

	State:		Zip:

Occupation:

	How Long:	years months

Monthly Salary
(before taxes): $

	Paid:

Your Next of Kin's Information

(someone not living with you)

Full Name:

Street Address:

	Apartment Number:

City:

	State:		Zip:

Spouse's Information

Full Name:

Maiden Name:

Would your spouse like to resume their maiden name?

Street Address:

	Apartment Number:

City:

	State:		Zip:

County/Parish:

	If Other:

If Calcasieu, then how long has your spouse lived in the Parish?

Phone Number:

	Work Phone Number:

Cell Phone Number:

	Alternate Phone Number:

Email Address:

Sex:

	Race		SSN: XXX - XX - :

Date of Birth:

Place of Birth City:

	State:

Number of marriages including this one?

Spouse's Educational History and Employment

Level of Education:

Place of Employment:

Street Address:

	Suite Number:

City:

	State:		Zip:

Occupation:

	How Long:	years months

Monthly Salary
(before taxes): $

	Paid:

Spouse's Next of Kin's Information

(someone not living with your spouse)

Full Name:

Street Address:

	Apartment Number:

City:

	State:		Zip:

Marital Information

Date of Marriage:

Place of Marriage:

	State:

Last home you resided as husband and wife:

Street Address:

	Apartment Number:

City:

	State:		Zip:

Date of Seperation:

What is your reason for filing divorce?

If you selected "Other", please explain:

Children Information

Were there any children born of the marriage or adopted?

If there are children, please list them below:

Child Name	Date of Birth	Gender

If more children need to be listed, please do so below:
(or refresh this page for extra blanks above)

Custody Information

If there are children, the present care and custody of those children is with:
(if it is you or your spouse please enter the name *exactly* as above)

Full Name:

Have you and your spouse agreed to a custody arrangement?

If "Yes", which arrangement?

If "Joint Custody", please list the domiciliary parent and the details

Domicilliary parent:

Full Name:

Joint Custody Details:

Bankruptcy and Support Information

Have you or your spouse ever filed bankruptcy?

If "Yes", when and where?

Date of Bankruptcy:

City of Bankruptcy:

	State:

Are you currently being ordered to pay child support for children not born of this marriage?

If "Yes", what amount? $

Are you receiving any type of support and/or benefits (Child Support, AFDC, Alimony, etc.) from the state or welfare office?

If "Yes", please specify:

Community Property Information

Is a community property partition needed in addition to your divorce?

If "Yes", please list the property to be divided:

Court Costs

Who will be responsible for the cost of court? (Court costs do not include the attorney's fees for either party)