Texas Instant Divorce :: Your Online Divorce Specialist

DIVORCE INTAKE FORM TWO

Please note: you are now initiating the order process. At the completion of this form, you will be asked to provide credit card information. Although you may choose to contact our staff and provide this information by telephone, your order cannot be processed until we have credit card data on file. Thank you for your cooperation with this policy.

Complete this form if you have property and/or children and you and your spouse are in agreement on these issues and your spouse will sign. If you have any questions, please call

800-760-6603

Do not leave any fields blank, use N/A if the question does not apply.

Provide Your Information
Full Name:
Street Address:
City:
County:
State:			Zip:
Work Phone:
Home Phone:
Email: (optional)
Are you currently in the military:
Provide Your Spouse's Information
We will NOT contact your spouse.
Spouse's Name:
Street Address:
City:
State:			Zip:
Work Phone:
Home Phone:
Is your spouse currently in the military:

Provide The Following Marriage Information
Date of Marriage:
Place of Marriage:
Separation Date:
Is Alimony to be Paid?
If yes, please enter the amount:			$
Alimony to be paid by:
To the best of your knowledge, is your combined income with your spouse above or below $50,000/year.
Above		Below

Provide Property and Debt Information
Husband transfers to Wife the following property and or assets:

Wife transfers to Husband the following property or assets:

Husband shall be responsible for paying the following debts:

Wife shall be responsible for paying the following debts:

* Please specify credit cards by the name of the issuing bank.

Wife's Former Name
Wife requests to have former name restored:
Please indicate former name:

Provide Minor Children Information
Names and Birthdates of Minor children you have with your spouse. Please include M (male) F (female) for each child.

List all addresses where the children have lived in the past 5 years:

Child Custody Information
Please indicate whether there has ever been any court proceeding prior involving the custody or support of the minor children. Please include the court and case number of any such proceeding:

Please indicate which spouse will have Primary custody of the minor children:
Please indicate whether visitation should be listed as:
If you indicated that visitation was to be "Supervised" or "Restricted" Please specify the terms of such visitation here:

Child Support Information
Please indicate the agreed upon amount for child support:		$ /per month
To be paid by:

OR
Would you prefer the amount of child support left blank so that the court may set it or you and your spouse may discuss an agreed upon amount and enter it on the form?
Medical insurance coverage for the minor children to be provided by:


Payment Information

Name on card:
Billing Address:
City:
State:			Zip:
Card Type:	Master Card Visa
Card Number:	We cannot complete your divorce until credit card information is provided.
3 digit security code on back of card:
Expiration Date:

Please review all your answers prior to submitting this form. Then press the Submit Form button only once.