DISSOLUTION QUESTIONNAIRE

YOUR PERSONAL INFORMATION

_________________________ _____________
NAME
DOB

_____________________
TIME IN ARIZONA

_________________________ ______________ ___________ ________________

ADDRESS
Home phone
Cell phone
Work ph.
_________________________ ______________ _____________________________
E-MAIL ADDRESS
OCCUPATION
EMPLOYER
_________________________ _____________
ANNUAL GROSS INCOME
SSN
(If you dont know, please estimate)
Please briefly describe your educational back ground. If you are currently in an educational or
training program, please provide the expected completion date.
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Please briefly describe your employment history for the past five (5) years.
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
YOUR SPOUSES PERSONAL INFORMATION:
_________________________ _____________
NAME
DOB

_____________________
TIME IN ARIZONA

_________________________ ______________ ___________ ________________

ADDRESS
Home phone
Cell phone
Work ph.
_________________________ ______________ _____________________________
E-MAIL ADDRESS
OCCUPATION
EMPLOYER
_________________________ _____________
ANNUAL GROSS INCOME
SSN
(If you dont know, please estimate)
Is spouse in military? Y/N

DOM/DISSOLUTION QUESTIONNAIRE

Please briefly describe your spouses educational back ground.

______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Please briefly describe your spouses employment history for the past five (5) years.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is your spouse currently represented by counsel? Y/N. Name: ____________________________

LEGAL PROCEEDINGS.
Have any legal proceedings been initiated? Y/N
If Yes, please bring copies of all legal pleadings, minute entry orders and the like in your
possession to your initial conference.
MINOR CHILDREN OF THIS MARRIAGE INFORMATION
Name
Date of birth
SSN #
Place of birth
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Please list the residences your children have resided at for the past five (5) years, and dates of
residence, if different to your current residence. Please also indicate with whom the children have
resided for the past five (5) years.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Please note, the Court requires disclosure of confidential information including security
numbers, but allows us to seal this information confidentially. We do not use or provide your
social security numbers or other confidential information to anyone unless compelled by law or
you authorize us to do so.

DOM/DISSOLUTION QUESTIONNAIRE

MARRIAGE INFORMATION:
_________________
Date marriage

____________________
Place of marriage

_________________
Maiden name

____________________
Do you wish it restored

Date of separation

Have you participated in or do you wish to participate in free marriage counseling through the
Superior Court? YES___ NO ___
Do you feel that your marriage is irretrievably broken? YES___

NO ___

CUSTODY INFORMATION:
Do you think that custody will be in issue? If yes, please describe custody issues as best as you
can. If not, please describe what you believe will be the custody arrangements.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
FINANCIAL INFORMATION:
BANK ACCOUNT/BROKERAGE AND CASH ON HAND INFORMATION:
BANK NAME
BROKERAGE

TYPE OF
ACCOUNT

DOM/DISSOLUTION QUESTIONNAIRE

ACCOUNT
NUMBER

BALANCE

TITLE

LIFE INSURANCE INFORMATION

COMPANY

OWNER

FACE VALUE CASH VALUE POL.NO.

REAL PROPERTY:
ADDRESS

TITLING INFO

VALUE

MORTGAGE

BUSINESSES:
COMPANY NAME % INTEREST

PARTNERS

VALUE

LIMITED PARTNERSHIPS:
NAME OF PARTNERSHIP PROP. HELD

DOM/DISSOLUTION QUESTIONNAIRE

TITLE

VALUE

RETIREMENT PLANS/IRASS/401(k):
PLAN NAME

OWNER

ACCOUNT INFO

VALUE

VEHICLES
YEAR

MAKE/MODEL

TITLE

BLUE BOOK LIENS

MISCELLANEOUS: Do not list specific items of personal property unless they are
particularly valuable or of particular interest to you.

5.

DEBTS

CREDITORS NAME CARDHOLDER

DOM/DISSOLUTION QUESTIONNAIRE

MONTH PAYMENT BALANCE

SEPARATE PROPERTY:
Separate property is that property obtained prior to marriage, or during the marriage by way
of gift or inheritance. Please list all property that you claim to be separate property. Please indicate
all paperwork to indicate this is separate property (such as: receipts; copies of prior Decrees, wills,
titles, etc.).
DESCRIPTION

HOW TITLED

VALUE

LIENS

Documents to verify that it is my separate property:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CONTESTED PROPERTY: Please indicate those items of property that you believe will be
contested and the claims by your spouse of which you are aware:
PROPERTY

CLAIMS

OTHER COMMENTS: Is there anything else you believe will be relevant to your legal
situation?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

DOM/DISSOLUTION QUESTIONNAIRE