Divorce and Legal Separation Information Form

General Contact Information: 

First Name:

Last Name:

Street Address:

City:

State:

Zip:

E-mail Address:

Home Phone:

Work Phone:

Pager/Cell Phone:

What method would you prefer we use to contact you?     Phone         E-mail       Fax

What time of day would you like us to call? Morning   Afternoon    Evening    N/A

Your date of birth:

On what  date were you married? 

In what city and state? 

Do you have a certified copy of your marriage license?    Yes      No

Are you a member of the Armed Forces? Yes      No
Leave following N/A, if answer is no.

Military branch or class:

Date Entered Military:

Rank/Rate/Pay Grade:

Duty Station:

Is your spouse a member of the Armed Forces?  Yes      No

 Are both parties residents and domiciliaries of Virginia? Yes      No

In what city and state did you and your spouse last live together?

Date of separation:

Is there a separation agreement?   Yes      No

Spouse Info:

Spouse's Full Name:

Spouse's Address:

Home Phone:

  Work Phone:

Pager/Cell Phone:

Spouse's Attorney:

Address of Attorney:

Maiden name of plaintiff or defendent:

Do you (or your spouse) wish to resume maiden or former name?: Yes      No

If so, former name if different from maiden:

Children Info (Leave as N/A if none)

Name:  

Date Of Birth:  

Name:  

Date Of Birth:  

Name:  

Date Of Birth:  

Name:  

Date Of Birth:  

Retained Clients Only

I understand and agree to the fee of $105.00 for up to one-half hour for a consultation.  If my consultation should exceed one-half hour, I understand that I will be billed at the hourly rate of $210.00 for any and all additional time spent with J.B. Thomas & Associates.  I agree to pay this consultation fee and understand that the fee for this consultation shall be applied toward the total attorney's fee if I retain the services of J.B. Thomas & Associates for this matter.

Yes - I agree        No - I disagree