Date: ______________________ RETURN TO: Attorney’s At Law
Return to: __________________ 1437 South Boulder Avenue, Suite 170
Atty: ______________________ Tulsa, Oklahoma 74119-3638
Retainer & Costs: ___________ (918) 396-4600
Date Paid: __________________ (918) 582-9940 Facsimile
DIVORCE QUESTIONNAIRE WITH CHILDREN
IT IS IMPORTANT THAT ALL BLANKS BE FILLED IN WITH THE INFORMATION REQUESTED, OR “UNKNOWN”, “NOT APPLICABLE”,, OR “NONE.”
YOUR FULL NAME: ______________________________________ Birth Date: _________
SSN: ________________ Drivers Lic. #: __________________Cell Phone: _____________
Home Address: ______________________________________________________________
County: ______________ Work Phone: ________________ Home Phone: ______________
Employer’s Name and Address: _________________________________________________
____________________________________________ Gross per Month: ________________
Pay periods, i.e., weekly, monthly, etc.: ___________________________________________
Any additional income: _______________________________________________________
(Please give all details, i.e. name, address and telephone number of each such additional source of income, monthly pay periods, monthly earnings from each such source, whether this is temporary, or permanent, and length of time such will continue).
SPOUSE’S FULL NAME: ________________________________ Birth Date: ___________
SSN: ________________________ Drivers License #:____________________________
Address: ___________________________________________________________________
County: _______________
Employer’s Name and Address: _________________________________________________
______________________________________________ Gross per Month: ______________
Pay periods, i.e., weekly, monthly, etc.: ___________________________________________
Any additional income: _______________________________________________________
(Give details requested above)
Do you and your spouse agree on the terms of this divorce? If so, will a Waiver be signed by your spouse? ______ If not, where is service to be made? ____________________________
(Specify days and hours of employment)
I / My spouse have/has been a resident of Tulsa/Osage/Creek/Washington/Wagoner County for 30 days. (Circle one)
I/ My Spouse have/has been a resident of Oklahoma for 6 months. (Cirlce one)
Date of Marriage: _______________________ City & State: _______________________
If separated, since when? _______________________________________________________
If common?law marriage, approximate date: ________________________________________
Does either party have pension funds, Keough plans, Erisa plans, or IRAs? ______ If so, who? _____ value: $ ______________ Is the participant of the fund or plan vested? _______________
Will you or your spouse be eligible for continuation of group health insurance through COBRA after this divorce is granted? __________ If so, what is the name of the group health insurance company? ____________________________________________________________________
PROPERTY (REAL AND PERSONAL)
List all real and personal property (including real estate [give the street address and legal description], vehicles, household furniture, household goods and furnishings), and a value for the items to be divided. Specify whether it was acquired during this marriage, or if it was acquired prior to this marriage.
PROPERTY REQUESTED BY YOU
(Check one)
Acquired Acquired
Description Value During Prior
________________________________________________________________________
PROPERTY FOR SPOUSE
(Check one)
Acquired Acquired
Description Value During Prior
DEBTS
Specify the creditor’s name, address, account number, approximate balance, designate which are joint or individual debts, and who is responsible for payment of each debt. Include mortgages, liens, credit cards, signature loans, student loans, etc.
DEBTS TO BE PAID BY YOU
Creditor’s name Joint or Prior to
and address Account No. Amount Individual or during
marriage
DEBTS TO BE PAID BY SPOUSE
Creditor’s name Joint or Prior to
and address Account No. Amount Individual or during marriage
Grounds for divorce: ____________________________________________________________
Do you and/or your spouse receive State (DHS) assistance? YES NO If yes, explain:________
______________________________________________________________________________
Accounting needed? ________ Restraining Order? __________ Assets order? ___________
Temporary support requested for client? _____How much? $________ Alimony requested? ___
If so, amount and reason: $_______________________________________________________
Have you filed Bankruptcy? YES NO If so, when was it discharged? ____________________
Restoration of maiden/former name? ______ If so, state name, and if it is maiden or former name:
________________ If publication, last address: _______________________________________
Other:
CHILDREN
Specify if born of this union or marriage, adopted by the parties, or adopted by step?parent.
Full SS Date of City and
Name No. Birth State Age
Who is to have custody of the children? ____________ Visitation privileges: _______________
Amount of monthly child care expenses for all children: ________________________________
Date due? _________Who is to maintain medical insurance for the above?listed children? _____
Amount of dependent premium only: $__________ (weekly, bimonthly, monthly, semi?annually, annually)? ____________________________________________________________________
How are deductible amounts and medical expenses not covered by insurance for the children to be divided? ___________________________________________________________________
If termination of parental rights, reason: _____________________________________________
List each child’s name, all addresses, periods of residence and the custodian’s name, address and relationship for each period of time with whom the children have lived during the past five (5) years is listed below:
Periods of Child’s Place of Custodian’s Name,
Residence Name Residence Relationship to
Child & Present
Address
ANSWER THE FOLLOWING QUESTIONS:
I have participated as a party, witness or in some other capacity in other litigation in this or some other state concerning custody, including visitation, of a child subject to this proceeding. YES NO (circle one)
If YES, state:
a. Name of each child involved:
b. Your capacity in the litigation:
c. Court, State & Case Number:
d. Date of last Court Order or Judgment, if any:
I have information concerning a custody proceeding pending in a Court of this or some other state concerning the custody of a child subject to this proceeding. YES NO (circle one)
If YES, state:
a. Name of each child involved:
b. Nature of proceeding:
c. Court, State & Case Number:
I know of a person who is not a party to this proceeding who has physical custody of or has or claims to have custody or visitation rights with a child who is subject to this proceeding. YES NO (circle one)
If YES, state:
a. Person’s Name and Address:
b. Name of Child involved:
c. _____ Has Physical Custody;
_____ Claims or Has Custody Rights;
_____ Claims or Has Visitation Rights.
SCHEDULE “3″
BUDGET WHILE LIVING SEPARATELY
1. Number of persons living in household: ___________________________
2. Name and Relationship of all members of the household whose expenses are included:
NAME RELATIONSHIP
________________________________________ ___________________
________________________________________ ___________________
________________________________________ ___________________
| Expense | Amount |
| 1. Rent or mortgage payments (residence) | $ |
| 2. Real property taxes (residence) | $ |
| 3. Real property insurance (residence) | $ |
| 4. Maintenance (residence) | $ |
| 5. Food and household supplies | $ |
| 6, Utilities including water, electricity, gas and heat | $ |
| 7. Telephone, mobile phone and pag!r | $ |
| 8. Laundry and cleaning | $ |
| 9. Clothing | $ |
| 10. Uninsured medical | $ |
| 11. Uninsured dental | $ |
| 12. Insurance (life, health, accident, comprehensive, liability, and disability) | $ |
| 13. Child Care | $ |
| 14. Payment of Child Support/Spousal Support (Prior Marriage) | $ |
| 15. School | $ |
| 16. Entertainment (includes clubs, social obligations, travel and recreation) | $ |
| 17. Incidentals (grooming, tobacco, alcohol, gifts and donations) | $ |
| 18. Transportation (other than auto) | $ |
| 19. Auto expense (gas, oil, repair, insurance, tag) | $ |
| 20. Auto payments | $ |
| 21. Installment payments (insert total and attach an itemized schedule) | $ |
| 22. Other expenses: | |
| TOTAL | $ |
2. Ex Parte Temporary Orders
Applications for ex parte temporary orders and ex parte emergency orders are heard by the Judge assigned to the case, as provided in Rule DR 1(3). If a restraining order is issued, a hearing will be set before the assigned Judge within ten (10) days. (43 OS. § 110)
RULE DR 4. Agreed or Default Decrees and Judgments
All requests to grant divorce decrees agreed to by the parties or sought by
default shall be heard only by a Judge assigned to the Family Division. These hearings shall be held from 9:00 a.rn, to 9:30 a.m. and 1:00 p.m. to 1:30 p.m.
RULE DR 5. Discovery
1. Within twenty (20) days of the date of service of summons or no later than 48 hours before the temporary order hearing, whichever is earlier, both parties shall exchange copies of the following documents:
a. An accurate and provable statement of the parties’ gross monthly
income supported by the preceding month’s payroll checks and check stubs, and evidence of all income received from all sources within ninety (90) days prior to the date of
service;
b. complete tax returns for three (3) years prior to date of service;
c. an accurate and provable statement of monthly employment?related
child care expenses;
d. evidence of medical insurance coverage and premium cost;
e. an accurate and provable list of all marital debts, stating the purpose
of the debt and the amount of monthly payments for all existing debts and obligations; and
f. an accurate and provable list of monthly living expenses.
2. All additional discovery shall be commenced within forty?five (45) days of the date of service of summons or notice of hearing, absent agreement of the parties or an order of the Court.
RULE DR 6. Pretrial Orders
All pretrial orders for Family cases must be submitted on the Family Divison pretrial order form available from the Court Clerk’s office.
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