Section I - Personal and Contact Information:

Note: All information put in Court documents becomes public record.  If you have information you wish to keep private please inform us of that when we call for your consultation.

What type of case is this going to be?

Your current status?

How did you first hear about us?

Who did you speak with from our office prior to completing this questionnaire?


What is the best phone number to reach you by during the day? Home Work Cell


Mailing address:


City   State Zip

Date of birth


Would you like for us to set your account up to receive text-alerts as your case proceeds?

Section 2 - Spouse Contact Information:


Cell phone

Work phone


Mailing or severable address:

Street   Apt.

City   State Zip

Date of birth

Your Spouse's Sex:

Section 3 - Marital Information

Is the wife pregnant?

Date of Marriage?

City and State of Marriage

Does wife want to change her name?

If yes, what is the name?

Is your spouse active duty military?

Have either you or your spouse had any minor children born to you since your date of marriage?


Section 4 - Division of Assets &Debts

What debts do you wish to assume?

All debts that are in my name  and/or all debts listed below:

What debts do you wish the other person to assume?

All debts that are in their name  and/or all debts listed below:

What is community property and sole and separate property

What property do you want to be awarded?

All property currently in my possession  and/or all property listed below:


What property do you want the other person to be awarded?

All property currently in their possession   and/or all property listed below:

We own a home.  This is what I would like done with your home(s):

Section 5- Spousal Maintenance (Alimony)

What is spousal maintenance/ alimony

If alimony is to be paid or received, how much is going to be paid?

If alimony is to be paid or received, for how long?  month(s), or  never ending, or   I do not know how much to ask for or for how long.

Section 6- Retirement Benefits


Section 7 - Process Service

A copy of the legal documents must be given to your spouse AFTER they have been filed with the Court.

What is the single best way you want to do this?

Do I need a Process Server? How does Process Service work.

How does Publication / Newspaper Divorce work?

Section 8 -Other information or comments

Section 9-Contact

Discount Divorce will immediately begin work on your case as soon as your initial phone consultation is complete and your payment is received.

Section 10 - Payment Info

All costs will be discussed with you in advance, and we will not proceed or charge your card until you instruct us to do so.

Pricing and cost information:

Number Exp. Date

CVV No. What is a CVV Number? Type of Card

Amount that will be charged after speaking with a Representative will be $99.

Would you like us to look into having the state's $341 filing fee deferred? Yes No

If yes, what is your average monthly income before taxes? $ and number of dependants?

Terms of Service

I acknowledge that I have read the "Terms of Service and agree and understand them. Yes No

Applicant Name/E-Signature: I certify that all information contained herein is true and correct.

Date (mm/dd/yyyy):