Mediated Dissolution of Parenting & Property

SERVING WAUKEGAN, LIBERTYVILLE, LAKE COUNTY, GURNEE & NEARBY AREAS OF ILLINOIS

MEDIATED DISSOLUTION INFORMATION SHEET
Date*
MM slash DD slash YYYY
WIFE PERSONAL INFORMATION
Name:*
Address:*
Date of Birth:*
Cell Phone*
Home Phone
Email Address*
Preferred method of contact
Maiden Name:
Birthplace:
Occupation:
Employer's Name:
Employer's Address:
Employer's Phone Number:
Salary$
Per
Time at present job:
Education - Highest Level of Education Completed:
Number of Other Marriages:
Dates Terminated:
Child Support Obligation(s) amount of payment and frequency of payment:
Orders of Protection:
Parties:
Date(s) order(s) entered:
Is an Order currently in effect and if yes, until what date is the order effective:
HUSBAND PERSONAL INFORMATION
Name:*
Address:*
Date of Birth:*
Cell Phone*
Home Phone
Email Address*
Preferred method of contact:
Maiden Name:
Birth Place:
Occupation:
Employer's Name:
Employer's Address
Employer's Phone:
Salary$
Per
Time at present job:
Education-Highest level of education completed:
Number of other marriages:
Dates Terminated:
Prior Child Support Obligation(s):
Orders of Protection:
Parties:
Dates:
Is Order in Effect:
MARRIAGE
State, City, and County of Marriage:
Date of Marriage:
MM slash DD slash YYYY
Living with Spouse Now:
If not, date separated:
Grounds for Dissolution:
Irreconcilable Differences
CHILDREN
Names
Date of Birth
Residence
Please indicate your desired allocation of parenting responsibility between you and your spouse.
1. Education
- Shared
- Sole decision making
2. Religious
- Shared
- Sole decision making
3. Medical
- Shared
- Sole decision making
4. Extra-curricular
- Shared
- Sole decision making
Please indicate the Allocation of Parenting Time for you and your spouse
1. Alternate weekends
2. Weekday time
3. Summer
4. Holiday
5. Vacation time
6. School breaks
Who will be allocated the majority of parenting time for school purposes?
Amount of Child Support: $
Any adopted children? (Names, Dates of birth):
Wife Pregnant?
Do the children own property other than personal effects?
If yes, identify:
College Information:
College attending:
Desired allocation of cost:
Tuition and related costs per semester:
MARITAL PROPERTY
Real Property
Address
Record Owners
FM Value
Date Acquired
Is any of the property producing revenue?
Name of Mortgage Company:
Mortgage Balance:
Vehicles
Type of Vehicle
Approximate Value
Loan or Owned Outright
Other Personal Property (family heirlooms, coin collections, artwork, jewelry, antiques, etc.)
Item
Value (If over $500.00)
Possession
Checking, Savings, CDs, Stocks, Bonds, IRAs
Institute
Owner
Value
Account or Certificate #
#Shares
Pensions & 401K Plans
Does Wife currently have a Pension or 401K Plan through her employer?
If so, list the type of account, approximate value and number and amount of any loans:
Does Husband currently have a Pension or 401K Plan through her employer?
If so, list the type of account, approximate value and number and amount of any loans:
NON-MARITAL PROPERTY
Item
Purchase date
Value
DEBTS
Creditor
Total Debt Due
Monthly Payment
Marital/NM
Please submit this intake sheet along with copies of both parties W-2s and income tax returns from last year, most recent three paystubs for this year, most recent retirement account statements, most recent account statements for any CDs, IRAs, bank accounts, credit card statements to our office prior to the mediation session.
Max. file size: 50 MB.
Date*
MM slash DD slash YYYY
Email Address:*
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Mediated Dissolution of Parenting & Property

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