Florida Intake Sheet

Please fill out this form, this information will assist us in helping you. All information on this form is confidential!

Today's Date * This field is required.
Did you learn of this Law Firm through: * William J. Leininger's television and radio appearances? (e.g. Phil Donahue, Today, Eyewitness News, etc.) Newspaper articles about William J. Leininger? This field is required.
Your Name: * This field is required.
Wife's Maiden Name: * This field is required.
Address: * This field is required.
Zip: * This field is required.
Telephone Number: * This field is required.
Cell Phone Number:
Email Address: * This field is required.
Your Employer: * This field is required.
Last Year's Income: * This field is required.
Years Florida Resident: * This field is required.
Date of Birth: * This field is required.
Place of Birth: * This field is required.
Social Security Number: * This field is required.
Date Married: * This field is required.
Place Married: * This field is required.
Prior Marriages: * This field is required.
Children's Names * This field is required.
Children's Ages * This field is required.
Religion: * This field is required.
Spouse's Name: * This field is required.
Spouse's Last Year's Income: * This field is required.
Spouse's Address: * This field is required.
Spouse's Zip: * This field is required.
Spouse's Employer: * This field is required.
Spouse's Years Florida Resident: * This field is required.
Spouse Date of Birth: * This field is required.
Spouse Place of Birth: * This field is required.
Spouse Social Security Number: * This field is required.
Spouse Religion: * This field is required.
Date Last Separated (if applicable)
Any other factors which you feel are significant?
Bank Accounts in Husband's Name Alone
Amount on Deposit in Each of Husband's Bank Accounts
Bank Accounts in Wife's Name Alone
Amount on Deposit in Each of Wife's Bank Accounts
List Bank Accounts in Joint Names of Husband & Wife
Amount on Deposit in Each of the Above Bank Accounts in Joint Names of Husband & Wife
Other Bank Accounts Not Listed Above in Which Husband or Wife Has an Interest
House Names on Deed
Present Fair Market Value of House Without Reduction for Amount of Mortgage
Amount of Existing Mortgage Balance
Monthly Mortgage Payment
List All Automobiles Owned by Either Spouse
Name on Title
List Any Outstanding Auto Loans, & List Which Auto Has the Loan & Present Loan Balance for Each Loan
List Principal Driver of Each Auto Listed Above
401(k) and IRAs (List name of financial institution, which spouse is owner, & present balance)
Pensions (List details of each pension & which spouse is owner & present balance):
Separate Property: (including inheritances, gifts other than from spouse; proceeds of negligence or Worker's Compensation claims which occurred during the marriage)
Additional Facts About Your Marriage Which you Feel May Be Significant:

Office Location

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