CONFIDENTIAL ATTORNEY CLIENT COMMUNICATION

THE PURPOSE OF THIS FORM IS TO ASSIST OUR OFFICE IN EFFECTIVELY REPRESENTING YOU BY ORGANIZING ALL OF THE RELEVANT INFORMATION ABOUT YOU AND YOUR FAMILY. PLEASE FILL OUT THE FORM CAREFULLY. PLEASE FILL IN THE FORM WITH A QUESTION MARK (?) IF YOU DO NOT KNOW THE ANSWERS OR IF UNSURE AND WRITE "NONE" IF APPROPRIATE. DO NOT LEAVE THE SPACES BLANK.

Please fill in all the information on this form, then click on the "Submit Form"  button to send the form to Heitke Law Office, LLC.

YOUR PERSONAL INFORMATION

Your Full Name
Maiden Name (if applicable)

IF RELEVANT, DO YOU WISH TO RETURN TO THE USE OF YOUR FORMER SURNAME (MAIDEN NAME) OR USE ANOTHER FORM OF A FORMER NAME?
 Yes   No

Specify new surname desired:
Current address:
City:
State:
Zip:
Your Social Security #:
Spouse's Social Security #:
Children's Social Security #(s):
Your Driver's License # (Required for Garnishment purposes):
Spouses Driver's License #:
Your Date of Birth:
Your Place of Birth:
Home Telephone Number:
Work Telephone Number:
Should we avoid calling you at work?  Yes   No
Fax Number:
Cell Phone Number:
Pager Number:
E-Mail Address:
Your Religion (optional):
Education (highest grade completed including college):
College:
Graduate School:
Degree(s) Earned:

YOUR SPOUSE'S INFORMATION

Spouse's Full Name:
Current address:
City:
State:
Zip:
Date of Birth:
Place of Birth:
Home Telephone Number:
Work Telephone Number:
Fax Number:
Cell Phone Number:
Pager Number:
E-Mail Address:
Religion (optional):
Education (highest grade completed including college):
College:
Graduate School:
Degree(s) Earned:

CURRENT MARRIAGE

Date of Marriage:
State of Marriage:
*** PLEASE PROVIDE A COPY OF MARRIAGE CERTIFICATE/LICENSE AT YOUR APPOINTMENT.
Children and Dates of Birth:
Children's Social Security Numbers:

PREVIOUS MARRIAGES

You:
When Married:
When Marriage Ended and Why?
Any children from this marriage:	Yes   No
If so, Names and Dates of Birth:
Is child support paid for any of these children?	Yes   No
If so, how much and frequency?

Spouse:
When Married:
When Marriage Ended and Why?
Any children from this marriage:	Yes   No
If so, Names and Dates of Birth:
Is child support paid for any of these children?	Yes   No
If so, how much and frequency?

CUSTODY ISSUES

Please detail any problems regarding support, custody or visitation with the children. You can skip this section if arrangements concerning these issues have worked out satisfactorily.

YOUR EMPLOYMENT

Occupation:
Job Title:
Employer Name:
Employer Address:
How long employed?
Earnings (please fax a paycheck/stub):

EMPLOYMENT – SPOUSE

Occupation:
Job Title:
Employer Name:
Employer Address:
How long employed?
Earnings (please fax a paycheck/stub):

HEALTH AND VARIOUS INSURANCES

Please set forth in detail any health problems that you and your spouse have, especially those having an effect on your/spouses ability to earn income.

Health Insurance Provider:
Who holds the insurance?
How is it paid for?
Dental Insurance:
Who holds the insurance?
How is it paid for?

LIFE INSURANCE

Please set forth the name of the name of the company, the amount of insurance, the insured party and the names of all beneficiaries:

LEGAL ACTIONS

Please advise as to whether or not there have been any legal actions started between you and your spouse or any minor children for divorce, separate, domestic abuse, DCYF involvement, bankruptcy, etc.

CIRCUMSTANCES SURROUNDING YOUR MARRIAGE

Please use this section to set out the problems in your marriage. Detail any instances of abuse or violence and behavior problems like alcohol and drug abuse, gambling or mental illness.

Is there any chance of reconciliation and/or do you wish to attend counseling for either your benefit or that of the children?
 Yes   No

REAL ESTATE

Marital Residence

Do you own your own home?	Yes   No
If yes, set out details below:
Address:
When did you buy the home?
How much did you pay for it?
What is the existing mortgage amount? (First and any subsequent mortgages, including lines of credit secured by the residence):
Where did you get the money for the down payment?
Mortgage Company Name(s) (Please include all mortgages):
What is your regular monthly payment?
In whose name is the title held?
Fair Market Value?

OTHER REAL ESTATE

Address:
When did you buy the property?
How much did you pay for it?
What is the existing mortgage amount? (First and any subsequent mortgages, including lines of credit secured by the residence):
Where did you get the money for the down payment?
Mortgage Company Name(s) (Please include all mortgages):
What is your regular monthly payment?
In whose name is the title held?
Fair Market Value?

PLEASE SUMMARIZE BELOW FOR ANY OTHER PARCELS OF REAL ESTATE HELD.

AUTOMOBILES

Please specify the year, make, model, how and when acquired. Present value, amount owed and payment amount for all family vehicles.

Specify which vehicle you would like to retain:

BANK ACCOUNTS

Please specify the name and address of the bank, the amount on deposit, the source of the funds, the age of the account and the name of the account owners for all bank accounts. Please remember to include often forgotten items like Christmas Club Accounts and children's savings accounts.

INVESTMENTS

Please list all shares of stock, securities, bonds, mortgages, and any other type of investment that you and your spouse have acquired either before the marriage or after. If you have any doubt about the identity of the assets, please list it anyway. Please identify the name of the owner to each asset.

BUSINESS INTERESTS

PLEASE IDENTIFY ANY AND ALL BUSINESS INTERESTS THAT YOU AND YOUR SPOUSE HAVE HAD EITHER BEFORE OR DURING THE MARRIAGE.

Business name and nature of business:

List the names of all persons involved in the business and the nature of their interest in the business:

Who has possession of the business records?

PENSIONS, RETIREMENT PLANS, IRA, ETC.

Please describe as fully as you can the pensions, retirement plans, IRS or other retirement interest that you or your spouse have now or that were acquired before the marriage. Whenever possible, please provide the name and address of the beneficiary of the plan or account and the name and address of the fiduciary that controls the money. Whenever possible, please provide copies of all statements showing the value of the plan or fund.

INHERITANCES

Please identify the source and amount of any and all trusts or estates of which you or your spouse or children are the beneficiaries.

DEBTS DUE TO YOU

Does anyone owe you or your spouse any money?
 Yes   No

If so, describe:

DEBTS

It is equally important to know about your debt situation as it is to know about your assets. Please list all debts, liabilities and obligations (including any back taxes). Please list the name of the creditor, what it was for, the amount that is owed and whether the debt is personal to you, your spouse or as a joint debt.

TAXES

Are your taxes current?
 Yes   No

Is there a return due?
 Yes   No

If there is a return due, list amount due.

GENERAL INFORMATION

Have you or your spouse suffered any losses due to fire, theft or gambling in the past five (5) years)?
 Yes   No

Have you or your spouse had any personal injuries either on the job or elsewhere that might give you a claim for compensation?
 Yes   No

Are either you or your spouse collecting unemployment or TDI, at the present time or within the last five (5) years?
 Yes   No

Have either you or your spouse filed for Bankruptcy protection in the last six (6) years?
 Yes   No

ADDITIONAL INFORMATION

Please use this space to make any particular comments that you think are important about your situation that you would like us to know.