Mediated Dissolution of Parenting & Property SERVING WAUKEGAN, LIBERTYVILLE, LAKE COUNTY, GURNEE & NEARBY AREAS OF ILLINOIS MEDIATED DISSOLUTION INFORMATION SHEETDate* MM slash DD slash YYYY WIFE PERSONAL INFORMATIONName:* Address:*Date of Birth:* Cell Phone*Home PhoneEmail 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 INFORMATIONName:* Address:* Date of Birth:* Cell Phone*Home PhoneEmail 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: MARRIAGEState, City, and County of Marriage:Date of Marriage: MM slash DD slash YYYY Living with Spouse Now:YesNoIf not, date separated: Grounds for Dissolution:Irreconcilable Differences CHILDRENNames 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 spouse1. Alternate weekends2. Weekday time3. Summer4. Holiday5. Vacation time6. School breaksWho will be allocated the majority of parenting time for school purposes? Amount of Child Support: $ Any adopted children? (Names, Dates of birth):Wife Pregnant?YesNoDo the children own property other than personal effects?YesNoIf yes, identify:College Information:College attending: Desired allocation of cost: Tuition and related costs per semester: MARITAL PROPERTY Real PropertyAddress Record Owners FM Value Date Acquired Is any of the property producing revenue?Name of Mortgage Company: Mortgage Balance: VehiclesType 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, IRAsInstitute Owner Value Account or Certificate # #Shares Pensions & 401K PlansDoes Wife currently have a Pension or 401K Plan through her employer?YesNoIf 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?YesNoIf so, list the type of account, approximate value and number and amount of any loans:NON-MARITAL PROPERTYItem Purchase date Value DEBTSCreditor 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:* Privacy Policy Δ