1. Personal Information
Employment and Income
*Required to give you information regarding alimony and child support, if applicable.
Historical Employment Information
Spouse Personal Information If yes, please complete below:
Spouse’s Employment and Income
Marriage Information *If so, please bring or email copies of all related documents.
Equitable Distribution (Assets and Liabilities) Real Estate and/or Property
Business Interests: *Please list any additional business interests on the back of this intake form.
Bank Accounts (Please List Bank Name, Who has access? Estimated Value?)
Credit Card Accounts (Please List Creditor Name, Who has access? Estimated Value?)
Retirement/401k/Pension Accounts (Please List Provider, Start Date and Estimated Value) *Please list any additional retirement accounts on the back of this intake form.
Stock/Bond and Other Accounts (Please list Provider, Start Date, Estimated Value) *Please list any additional accounts on the back of this intake form.
Life Insurance Policie (Please List Provider, Name of Insured, Cash Out Value): *Please list any additional life insurance policy accounts on the back of this intake form.
School Loans (Please List Provider, Loan During Marriage? and Amount) *Please list any additional loans on the back of this intake form.
Additional Liabilities
Vehicles
“Toys” (Boats, Water Toys, Motorcycles, RVs, etc.)
Children (only complete for children belonging to you and your spouse, if applicable)
List all residence addresses for the children during the past 5 years. If any child lived with anyone except you and your spouse, give the name and address of the custodian, and the dates resided with the custodian.
If you and the other party have separated, have you been following any type of timesharing schedule? If yes, please explain below:
Does this schedule work for you? If not, please describe the schedule you would prefer below:
If YES:
List your most important priorities by assigning numbers, with #1 being the highest priority: Visitation Child custody Child support Property distribution Alimony Attorney's fees Restraining abusive spouse Other (specify)
Additional Information
Were you referred to this office by someone? YES/NO
Please list any goals you have in regards to this consultation and your potential dissolution of marriage:
Agreement for Consultation 1. You have requested a consultation with Jessica Langley Lowe, P.A. (Firm). By signing below, you acknowledge that the Firm does not represent you and that you have not retained the Firm to represent you or to appear as your attorney of record in your case. If you wish for representation by the attorney(s) at the Firm, you and the Firm must mutually agree to same, and you will be asked to sign a Retainer Agreement authorizing the Firm to represent you, and pay the agreed upon retainer fee.
2. The agreed fee is $100.00 for a consultation lasting up to forty-five minutes. This is a non-refundable, flat rate fee.
3. No attorney or law firm can guarantee a result in your particular case. While we can evaluate the strengths and weaknesses of your case, we cannot guarantee or give advice regarding a specific result. Further, the client understands that a consultation alone does not allow enough time and/or does not give enough information for the attorney to fully evaluate your case or to become familiar with all relevant facts necessary for same. As such, by signing below, client understands that the attorney's work on this case is limited to giving information about the firm and general impressions and good faith observations regarding your case, based on the information provided to the Attorney, during this session.
Any and all information provided herein is strictly confidential and is provided on the understanding that it will be held confidential.
By signing below, I hereby affirm that all of the information provided herein is true and correct and that I have completed it to the best of my ability at this time. Also, by signing below, I understand that at this time, the law firm of Jessica Langley Lowe, P.A. (Firm) and its’ undersigned attorney(s) have not been retained for my case and that a separate agreement must be signed. I understand that my consultation alone does not mean that this Firm represents me in my case.
Signature Date
