Carlo Forzani LLC
43 Woodland Street, Suite 500, Hartford, Connecticut 06105 Telephone: 860-251-6790 Fax: 860-251-6798
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PERSONAL AND MARITAL WORKSHEET

(confidential internal document; please give complete data; explain where desirable)

 

 

WIFE

 

Full birth name                                                              Current name (how you sign checks)

 

________________________________                                __________________________________

 

Home                                                        Office                                                    Mailing Address

(address & telephone)                (entity, address & telephone)             (home, office or other)

_____________________                      ________________________         ________________________

_____________________                      ________________________         ________________________

_____________________                      ________________________         ________________________

_____________________                      ________________________         ________________________

 

Fax number                                                 E-mail address                                 Cell phone number

_____________________                                  ____________________             _____________________

 

     Private to you?  ______

 

 

Date & place of birth                                                           Social Security number

_______________________________                                  ____________________________________

_______________________________

 

Resident of Connecticut since ________________

 

Religious preference ________________________

 

Serious health problems during marriage ____________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

 

 

Prescription medication (in past year) _______________________________________________

________________________________________________________________________________

 

 

Education (school, year & level completed):

 

High School                                               College                                           Graduate School

 

_____________________                      _____________________                       __________________________

_____________________                      _____________________                       __________________________

_____________________                      _____________________                       __________________________

 

 

Family of origin (names, addresses and, if deceased, year):

 

    Mother                                               Brother(s)                                               Sister(s)

_______________________            _______________________            __________________________

________________            _______            _______________________            __________________________

_______________________            _______________________            __________________________

                                                            _______________________            __________________________

    Father                                    _______________________            __________________________

_______________________            _______________________            __________________________

_______________________            _______________________            __________________________

_______________________            _______________________            __________________________


HUSBAND

 

Full birth name                                                              Current name (how you sign checks)

 

________________________________                                __________________________________

 

 

Home                                                        Office                                                    Mailing Address

(address & telephone)                (entity, address & telephone)             (home, office or other)

_____________________                      ________________________         ________________________

_____________________                      ________________________         ________________________

_____________________                      ________________________         ________________________

_____________________                      ________________________         ________________________

 

Fax number                                                 E-mail address                                 Cell phone number

_____________________                                  ____________________             _____________________

 

     Private to you?  ______

 

 

Date & place of birth                                                           Social Security number

_______________________________                                  ____________________________________

_______________________________

 

Resident of Connecticut since ________________

 

Religious preference ________________________

 

Serious health problems during marriage ____________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

 

 

Prescription medication (in past year) _______________________________________________

________________________________________________________________________________

 

 

Education (school, year & level completed):

 

High School                                               College                                           Graduate School

 

_____________________                      _____________________                       __________________________

_____________________                      _____________________                       __________________________

_____________________                      _____________________                       __________________________

 

 

Family of origin (names, addresses and, if deceased, year):

 

    Mother                                               Brother(s)                                               Sister(s)

_______________________            _______________________            __________________________

________________            _______            _______________________            __________________________

_______________________            _______________________            __________________________

                                                            _______________________            __________________________

    Father                                    _______________________            __________________________

_______________________            _______________________            __________________________

_______________________            _______________________            __________________________

_______________________            _______________________            __________________________

 

 

 

 

 

PRESENT MARRIAGE

 

Summarize courtship, beginning when you first met            Reasons for marrying spouse

____________________________________________            ________________________________

____________________________________________            ________________________________

____________________________________________            ________________________________

____________________________________________            ________________________________

____________________________________________            ________________________________

____________________________________________            ________________________________

 

Wedding:     

     

   Date                             City                                  County                                                   State

 

_______            ____________________      ____________________    ____________________

 

 

Summarize marital relationship before serious problems _______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

 

Children:

 

Full name                          Birthdate      Sex          School & Grade                   Residence

_______________________            ________     ___            ___________________            _______________

_______________________            ________     ___            ___________________            _______________

_______________________            ________     ___            ___________________            _______________

_______________________            ________     ___            ___________________            _______________

_______________________            ________     ___            ___________________            _______________

_______________________            ________     ___            ___________________            _______________

 

 

First serious marital problems

(date & description)  ______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________

 

 

Prior separation(s)                                                                       Final separation

(date(s) & description)                                                 (date & cause)

_____________________________________                    _____________________________________

_____________________________________                    _____________________________________

_____________________________________                    _____________________________________

 

Sexual relationship:

 

Frequency            _____________________

 

Quality            _____________________

 

Ceased?            _____________________

 

 

Three most negative things your spouse could say and prove about you with respect to breakdown of the marriage:            _____________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

 

 

Three most negative things you could say and prove about your spouse with respect to breakdown of the marriage:            _____________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

 

 

Have you had sexual relations with anyone other

than your spouse since your marriage?            _____________

 

Specific factors in marital breakdown (explain if applicable):

 

Physical abuse   ____________________________________________________________

Verbal/emotional abuse            _____________________________________________________

Lack of loving relationship  ___________________________________________________

Lack of concern for children   _________________________________________________

Emotional/health problems  ___________________________________________________

Alcohol/drugs  ______________________________________________________________

Financial/employment difficulties   _____________________________________________

Other            _____________________________________________________________________

 

Relationship with other person?

 

Description ________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

 

Witnesses  _________________________________________________________________

________________________________________________________________________________     

 

Documentary evidence (letters, photographs, etc.)  _______________________________

________________________________________________________________________________

 

Knowledge of your spouse____________________________________________________

 

 

 

PRIOR MARRIAGE(S) (both spouses)

 

Name of husband/wife  ____________________________________________________________

 

Year of marriage  _________________________________________________________________

 

Termination (how, year & place)  ____________________________________________________

 

Children:

                                                                                        School                                                           Supported

Name                                     Birthdate      Sex           & Grade                         Residence           by       

__________________            ________     ___            ______________            _____________            _________

__________________            ________     ___            ______________            _____________            _________

________________            __            ________     ___            ______________            _____________            _________

__________________            ________     ___            ______________            _____________            _________

__________________            ________     ___            ______________            _____________            _________

 

RECONCILIATION POSSIBILITIES

 

Counseling (names, addresses, dates, participants):

 

   Psychotherapist         Marriage Counselor                    Clergy                                    Psychiatrist

________________                 _________________             ___________________     __________________

________________                 _________________             ___________________     __________________

________________                 _________________             ___________________     __________________

________________                 _________________             ___________________     __________________

 

 

Your present feeling toward spouse  ________________________________________________

________________________________________________________________________________

 

 

Spouse's present feeling toward you  ________________________________________________

________________________________________________________________________________

 

 

Spouse interested in another person?   __________

 

  Name & Address                        When Started                    Marital Status            Extent of Relationship

________________                       ________________                 _______________ ___________________

________________                       ________________                 _______________ ___________________

________________                       ________________                 _______________ ___________________

 

 

Are you interested in another person? ___________

 

  Name & Address                        When Started                    Marital Status            Extent of Relationship

________________                       ________________                 _______________ ___________________

________________                       ________________                 _______________ ___________________

________________                       ________________                 _______________ ___________________

 

 

Is termination of marriage best solution?  ____________________________________________

 

Why?  _____________________________________________________________________

 

Spouse's attitude toward termination  __________________________________________

 

 

DIVORCE

 

Possible lawyer for spouse  __________________________________________________

 

 

Financial arrangements needed immediately?  _________________

 

 

Long-range financial settlement (probability) ____________________________________

________________________________________________________________________________

 

 

Child custody and access (anticipations)  _______________________________________

________________________________________________________________________________

 

 

Wife want return to birth name? ___________

 

 

GENERAL

 

Prenuptial or other written marital agreement?  _______________________________________

 

Annual income of wife                                                    Annual income of husband

 

______________________________                          ____________________________________

 

 

Assets (value of $10,000 or more):

 

Home & other real estate                                                 Bank accounts & CDs

______________________________                          ____________________________________

______________________________                          ____________________________________

______________________________                          ____________________________________

______________________________                          ____________________________________

           

 

Securities                                                                             Retirement (IRAs, pensions)

______________________________                          ____________________________________

______________________________                          ____________________________________

______________________________                          ____________________________________

______________________________                          ____________________________________

 

           

Professional practice/business                                      Other

______________________________                          ____________________________________

______________________________                          ____________________________________

______________________________                          ____________________________________

______________________________                          ____________________________________

           

 

Wills or trusts in existence  ________________________________________________________

________________________________________________________________________________

 

Mail (special instructions for sending)  _______________________________________________

 

 

Objectives:

 

Preserving marriage/reconciliation _____________________________________________

 

Divorce  ___________________________________________________________________

 

Financial __________________________________________________________________

 

Timing  ____________________________________________________________________

 

 

Accountant (name & address) ______________________________________________________

________________________________________________________________________________

 

 

Lawyer(s) with whom you or spouse have had professional relationship  __________________

________________________________________________________________________________

 

 

Who referred you to this firm? ______________________________________________________

 

 

 

Signature:            _______________________________________  Date:  _____________________
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