1. Legal Services of Northern Virginia Divorce Intake
Questionnaire
Please fill in this paper the best you can before you come in for your appointment.
PRINT your answers.
For some answers, you can circle the Yes/No type of choices. Fill in all blanks, and with either
an answer or a cross out, so that the form can be scanned by the attorney.
Circle whether you are husband wife
How well do you understand Good Poor Other (explain)
English?
What is your preferred
language(s) other than
English?
Do you have a friend who can
translate for you during visits to
an attorney’s office? If you do,
give name and phone
number(s):
Husband’s information:
FULL Name and last known address of Husband:
Does the husband actually live there Yes No
now?
If he does not live there now, what are
alternate ways to contact him?
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2. City/County of husband’s last known address:
home work cell
phone: phone: phone:
Husband’s email addresses: Husband’s race:
SSN: Driver’s license # & state
Date of State/Foreign
birth Country of birth:
# prior marriages: Highest grade
completed:
Wife’s information:
FULL Name and last known address of Wife:
Does the wife actually live there Yes No
now?
If she does not live there now,
what are alternate ways to
contact her?
County of the wife’s last known
address
Wife's FULL former (maiden)
name
Does the wife want to get her
former name back?
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3. home work cell
phone: phone: phone:
Wife’s email addresses: Wife’s race:
Wife’s email addresses:
SSN: Driver’s license # &
state
Date of State/Foreign
birth Country of
birth:
# prior marriages: Highest grade completed:
Your prior address (if you have
resided in the Commonwealth of
Virginia for less than 6 months)
Facts about the marriage and separation:
Date of Place of Marriage:
marriage:
Date of last
separation:
Circumstances of separation:
Have you or your spouse lived in You? Spouse?
Virginia and considered Virginia to
be his/her home for the last six
months?
What is the address where
you and your spouse last
lived
City/County of last address
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4. Have you discussed divorce with your Yes No
spouse?
If so, what is your spouse’s position?
Has your spouse already filed for divorce?
If so, have you provided a copy of the
pleadings?
Is filing for divorce likely to provoke an Yes No
adverse reaction from your spouse?
If so, explain
Has a reconciliation taken place since the Yes No
separation?
If so, what is the date of the last
separation (one not followed by a
reconciliation).
Corroborating witness (needed to testify to jurisdiction and grounds of divorce):
What is the name, address and phone
number(s) of a witness you can call to
testify to the fact:
(a) that you have lived in Virginia and
considered Virginia to be your home for
the last six months, and
(b) that you have been separated the
requisite time? (one year except if there
is a written separation agreement and no
minor children, in which case a six month
separation will do).
How do you know this
witness?
How long have you known
this witness?
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5. How often does this witness
come to your home?
Have you met with an attorney before? Yes No
If yes, give the attorney’s name, address
and phone number(s).
What did the attorney do for you?
Has your spouse met with an attorney? Yes No
If yes, give the attorney’s name, address
and phone number(s), if you know them.
What did the attorney do for your
spouse?
Children
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6. Were any children born to Yes No
both you and your spouse?
If so, give the full name, Full name SSN Date
Social Security number & date of Birth
of birth of each child
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7. Has custody or visitation for a Yes No
minor child ever been
determined by a written
agreement or by a court
order?
If so, have you given LSNV a
copy of the written
agreement and court order?
If so, who has custody, for
which child?
Has paternity ever been Yes No
questioned for any of the
minor children of both you
and your spouse? If so, give
details.
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8. Were any minor children Yes No
adopted by both you and your
spouse?
If so, have you given LSNV a
copy of the adoption decree?
Were any children born Yes No
during the marriage that were
not the children of both you
and your spouse?
If so, have you given LSNV a
copy of written any
agreement or court order?
Child support
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9. Has child support been Yes No
determined for all of the
minor children of both you
and your spouse?
If so, have you given LSNV a
copy of written the written
agreement or court order?
Has a written agreement or
court order required either
you or your spouse to provide
health care coverage to the
minor children of you and
your spouse?
If so, have you given LSNV a
copy of the written
agreement or court order?
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10. Are all minor children of both Yes No
you and your spouse covered
by health insurance?
Has a written agreement or Yes No
court order required you or
your spouse to maintain life
insurance for the benefit of
your minor children?
Have you provided LSNV with Yes No
a copy of the written
agreement or court order.
Is the person paying support Yes No
(and providing health and/or
life insurance coverage) doing
so, and current on those
obligations?
If not, explain.
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11. Spousal support:
Spousal Support, also known Yes No
as alimony, is money paid by
one spouse to the other, to
enable the other to meet his
or her living expenses. Has
spousal support been
required by a written
agreement or court order?
If so, have you given LSNV a
copy of written the written
agreement or court order?
Do you need spousal support Yes No
from your spouse?
Military spouse. Is your spouse on Yes No
active duty with one of the armed forces
of the U.S.?
If so, what is his/her home state of
record?
Incarcerated spouse. Is your spouse Yes No
incarcerated?
If so, where, and for how much longer?
Agreement between spouses?
Is there a written agreement between Yes No
you and your spouse or a court order that
has not been provided to LSNV?
Retirement benefits from employment:
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12. Do you think your spouse has any Yes No
retirement benefits from
employment, like a 401k or the
right to a pension upon
retirement?
If you do, describe them
What is your best guess as to the
value of your spouse’s retirement
benefits?
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13. Unless you are certain that your
spouse has no retirement benefits,
identify your spouse’s employers
from the time of the beginning of
the marriage until the last
separation
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14. Do you have any retirement Yes No
benefits?
If you do, describe them
What is your best guess as to the
value of your retirement benefits?
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15. If you do not know the
approximate value of your
benefits, can you provide LSNV
with copies of the statements you
have recently received about those
benefits?
Other property:
Did you or your spouse, either alone or Yes No
together, own a home purchased during
the marriage?
If you do, when was it purchased, and
what down payment was made?
Whose names are on the deed?
Whose names are on the mortgages:
If the home was sold, how much money
would you and your spouse receive?
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16. Do you or your spouse, either alone or Yes No
together, own [or are either of you in the
process of buying] a motor vehicle (car,
van, truck, motorcycle)?
If so, whose names are on the title?
If so, is the vehicle worth more than is
owed on it?
Who signed the notes secured by the
vehicles?
Who uses(considers as his/her own)
which vehicles?
Are you in possession of “your” vehicle?
Do you or your spouse, either alone or Yes No
together, have any checking or savings
accounts, or other accounts at a financial
institution?
If so, name all of the owners, identify the
financial institution, and estimate the
value of each account.
If you suspect that your spouse has
valuable financial accounts, but you do
not know the details, what details do you
know?
Did the money in the accounts all come
from the earnings of either you or your
spouse during the marriage?
If not, where did the money came from?
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17. Do you or your spouse, either alone or Yes No
together, have any other valuable
property that you got during the
marriage?
If so, describe it and estimate its value.
Marital debt: List all marital debts
(debts incurred by either you or your
spouse during the marriage prior to the
last separation of the parties), and tell me
who is liable on each debt.
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18. Do you need relief from a court with Yes No
respect to your burden of existing marital
debt?
If so, explain.
Has any marital debt resulted in a Yes No
judgment against you? If so,
(1) state
(a) creditor’s name,
(b) amount of judgment,
(c) reason for owing the money,
(d) whether there is any co-debtor, and
(e) who the codebtor is, and
(2) get copy of
(a) the court judgment, and
(b) any subsequent court papers, such
as garnishments against you.
Is there a written agreement between Yes No
you and your spouse about who is
responsible for marital debt?
If so, have you provided LSNV with a
copy of the written agreement?
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19. Bankruptcy. Has either you or your Yes No
spouse filed for a bankruptcy in the past?
If so, was the bankruptcy case filed with
the Alexandria bankruptcy court?
If not, where was the bankruptcy filed?
Do you suspect that your spouse will Yes No
want to file for bankruptcy, and leave you
alone responsible for marital debt?
If so, give details.
DOCUMENTS CHECKLIST:
___ Marriage Certificate
___ Current Custody Order (if applicable)
___ Current Child Support Order (if applicable)
___ Current Spousal Support Order (if applicable)
___ Property Settlement Agreement (if applicable)
___ All previous divorce decrees (if applicable)
___ Other Documents
_____________________________
____________________________ _________________________________
Name of Interviewing Attorney or Paralegal Organization of Volunteer (NCAPA, Freddie Mac
or LSNV)
________________________________ _________________________________
Name of Interpreter, if any Organization of Interpreter
______________________________________ _________________________________
Date of Interview Time Spent
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