Client Interview Form

ANNULMENT OF MARRIAGE
INTERVEWER : ___________________________________
DATE
: ___________________________________
Information about the client:
Name:
________________________________________________________
LAST
FIRST
MIDDLE
Maiden Name (if applicable):
________________________________________________________
LAST
FIRST
MIDDLE
Gender
: ____________________________________
Nationality
:
____________________________________
Date of birth
: ____________________________________
Place of birth
: ____________________________________
Social Security Number :
____________________________________
Driver's License Number: ___________________________________
Highest Educational Attainment:
_____________________________
Address:

Contact Numbers:
Home
: _____________________________________________
Mobile
: _____________________________________________
Email Address: ___________________________________________

Employment:
Employer : _____________________________________________
Job Title : _____________________________________________
Address : _____________________________________________
Telephone number: _______________________________________
Gross salary per month or annually:
__________________________
Length of employment: _____________________________________

Information about the spouse:

Page 1 of 5

Name:
________________________________________________________
LAST
FIRST
MIDDLE
Maiden Name (if applicable):
________________________________________________________
LAST
FIRST
MIDDLE
Gender
: ____________________________________
Nationality
:
____________________________________
Date of birth
: ____________________________________
Place of birth
: ____________________________________
Social Security Number :
____________________________________
Driver's License Number: ___________________________________
Highest Educational Attainment:
_____________________________
Address:

Contact Numbers:
Home
: _____________________________________________
Mobile
: _____________________________________________
Email Address: ___________________________________________
Employment:
Employer : _____________________________________________
Job Title : _____________________________________________
Address : _____________________________________________
Telephone number: _______________________________________
Gross salary per month or annually:
__________________________
Length of employment: _____________________________________

Information about the Marriage:

Date of Marriage
:
_________________________________________
Place of Marriage: _________________________________________
Was the wedding a civil ceremony or religious ceremony:
_________
Date you stopped living together:
____________________________
Address at which you last lived together:
Page 2 of 5

Do you have a written legal separation agreement?

______________
If so, give date of agreement: _______________________________
Check as appropriate if your marital difficulties involve any
of the following:
Drugs/alcohol
[_____]
Physical violence [_____]
Sexual disappointment [_____]
Religion
[_____]
Sexual infidelity
[_____]
Financial disputes
Other

[_____]

Incompatibility

[_____]
[_____] Please specify:

Information about Children:

Name of Child 1
:
____________________________________
Gender
: ____________________________________
Birth date
: ____________________________________
Birthplace
: ____________________________________
Address where child presently resides:

Name

of Child 2

____________________________________
Gender
: ____________________________________
Birthdate
: ____________________________________
Birthplace
: ____________________________________
Address where child presently resides:

Name

of Child 3

____________________________________
Gender
: ____________________________________
Birthdate
: ____________________________________
Birthplace
: ____________________________________
Address where child presently resides:
Page 3 of 5

Will there be a dispute over custody of the children?

YES [_____]
NO [_____]
If not, custody will be with whom?
____________________________
INFORMATION

CONCERNING

PETITIONERS

CHARACTER REFERENCES:
1. Name

_________________________________________
Address

: _________________________________________

Contact Number: _____________________________________

2. Name

_________________________________________
Address

: _________________________________________

Contact Number: _____________________________________

3. Name

_________________________________________
Address

: _________________________________________

Contact Number: _____________________________________

__________________________
Clients Name and Signature

Page 4 of 5

__________________________
Interviewers Name and Signature

Page 5 of 5