EmailMe Form - Separation Agreement:

Email *

Initial below to agree to the above terms of representation. *

Type your name initials here to confirm you understand.

Client FULL NAME (First/Middle/Last)* Suffix (Jr., III, etc.) *

First Middle Last Suffix

Client Maiden Name

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

In which city or county is this address located? *

Date of Birth *

MM / DD / YYYY

Primary Phone Number *

### - ### - ####

Work Phone Number

### - ### - ####

Number of this Marriage (1st, 2nd, etc.)? *

Race (White, Hispanic, African-American, etc.) *

Place of Birth (State/Country) *

Education (Highest grade completed) *

Spouse:

Spouse FULL NAME (First/Middle/Last)* Suffix (Jr., III, etc.) *

First Middle Last Suffix

Spouse Maiden Name

Spouse Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

In which city or county is this address located? *

Spouse's Race (White, Hispanic, African-American, etc.) *

Spouse: Number of this Marriage (1st, 2nd, etc.)? *

Spouse: Date of Birth *

MM / DD / YYYY

Spouse: Place of birth (State/Country) *

Spouse: Education (Highest grade completed) *

Date of Marriage *

MM / DD / YYYY

Place of Marriage (City/County/State) *

Address where last lived together

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

In which city or county is this address located? *

Date of Separation *

MM / DD / YYYY

Still living together? *

Yes

No

Children: List the FULL NAME(S) and Date(s) of Birth of minor and ADULT Children

Tell us what you have agreed upon about the children’s custody and visitation

Tell us what you have agreed to, if anything, about child support

MOTOR VEHICLES: List the Year, Make, Model, Name Titled In, and the Bank Holding the Lien on all vehicles

Tell us what you have agreed upon about the motor vehicles

REAL ESTATE: Provide property description, date acquired, how titled, and banks holding liens for all property

Tell us what you have agreed about the real estate

SAVINGS/CHECKING ACCOUNTS, STOCKS, BONDS, RETIREMENT ACCOUNTS: List Types of accounts, Approximate Balances and Where Held for all accounts

Tell us what you have agreed upon about these accounts

OTHER TANGIBLE PERSONAL PROPERTY (furniture, appliances, etc): Have you already agreed on a division of your tangible personal property? If so, the agreement will contain a general provision which reads as follows:“Except as otherwise provided herein, the parties have agreed as of the date hereof on a division of all other tangible personal property to their mutual satisfaction and do not feel it necessary to set forth said division herein.”

Yes

No

Will the agreement require exhibits showing item-by-item who gets what? (If yes, please prepare the lists)

Yes

No

HOSPITALIZATION/MEDICAL/DENTAL INSURANCE: List Company & Employer for Husband’s Present Hospitalization/Medical Insurance

HOSPITALIZATION/MEDICAL/DENTAL INSURANCE: List Company & Employer for Wife’s Present Hospitalization/Medical Insurance

Tell us what you have agreed upon about the insurance

JOINT MARITAL DEBT ONLY: List Creditor(s), Amount(s) owed, Monthly payment(s) and whether Joint/Husband/Wife for ALL debts

Tell us what you have agreed upon about the debts

Tell us what you have agreed upon about filing federal and state income tax returns

SPOUSAL SUPPORT: Do either of you want spousal support?

Yes

No

SPECIAL PROVISIONS: Tell us about any other agreements, lack of agreements, or other information you think important