Divorce Intake Form Client InformationClient's First Name:(Required) Client's Middle Name: Client's Last Name:(Required)(example: Smith Jr) Choose Divorce OptionChoose either 5 Week Divorce, 2 Week Divorce, or Publication Divorce. No Court Appearance Required For All Options.Click Drop Down Arrow to Make Choice5 Week Divorce2 Week DivorcePublication DivorceGender: Male Female Client's Full MAIDEN Name: Name ChangeAre you requesting a name change? Yes No What would you like your name changed to?In a divorce, you can change your name to your maiden name or a former married name only. First Middle Last Do you have former names other than your maiden name? No Yes, 1 former name Yes, 2 former names List your former name belowInclude: first, middle, and last names; even if one is the same now. First Middle Last List your second former name belowInclude: first, middle, and last names; even if one is the same now. First Middle Last Marriage DetailsDate of Marriage: MM slash DD slash YYYY Place of Marriage: Date of Separation: MM slash DD slash YYYY Do you already have a signed Separation and Property Settlement Agreement? Yes No PhonePhone #:(Required)Primary Phone NumberPhone #2:Phone #3:EmailEmail Address:(Required)Primary Email Address Other Email: Physical AddressStreet Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mailing Address(if different from Physical Address)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Client Residency StatusAre you currently a Virginia resident? Yes. I have lived in Virginia continuously for at least 1 year. Yes. I have lived in Virginia continuously for less than 1 year. No Yes. I am on active duty in the U.S. Armed Forces and have been stationed in Virginia for at least 1 year. Yes. I am on active duty in the U.S. Armed Forces and have been stationed in Virginia for less than 1 year. I have lived in Virginia Since:(less than 1 year residency) MM slash DD slash YYYY I have been stationed in Virginia since: MM slash DD slash YYYY Spouse Residency StatusIs your spouse currently a Virginia resident? Yes. My spouse has lived in Virginia continuously for at least one year. Yes. My spouse has lived in Virginia continuously for less than one year. No Yes. My spouse is on active duty in the U.S. Armed Forces and has been stationed in Virginia for at least one year. Yes. My spouse is on active duty in the U.S. Armed Forces and has been stationed in Virginia for less than one year. My spouse has lived in Virginia since:(resident less than 1 year) MM slash DD slash YYYY My spouse has been stationed in Virginia since: MM slash DD slash YYYY Spouse InformationWill your spouse sign a document agreeing to the divorce? Yes No Unsure Cannot locate spouse Spouse's First Name: Spouse's Middle Name: Spouse's Last Name:(example: Smith Jr) Spouse's full maiden name (if applicable): What is your spouse's gender? Male Female Spouse Name ChangeIs your spouse requesting a name change? Yes No What does your spouse want to change their name to?In a divorce, your spouse can change their name to their maiden name or a former married name only. First Middle Last Does your spouse have any former names other than their maiden name? No Yes, 1 former name Yes, 2 former names List your spouse's former name belowInclude all 3: first, middle, and last names; even if one is the same now. First Middle Last List your spouse's second former name belowInclude all 3: first, middle, and last names; even if one is the same now. First Middle Last Spouse's Contact Information(If current address is unknown, please enter the last known address.)Spouse's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Spouse's PhoneSpouse's Phone #:Primary Phone NumberSpouse's Phone #2:Spouse's Phone #3:Spouse's EmailSpouse's Email Address:Primary Email Address: Spouse's Other Email: ChildrenHow many children were born to or adopted by you and your spouse?(Please include all children regardless of age) 0 1 2 3 4 5 6 7 8 Child One: First Middle Last Child One Date of Birth: MM slash DD slash YYYY Child One is Living With: First Last Child Two: First Middle Last Child Two Date of Birth: MM slash DD slash YYYY Child Two is Living With: First Last Child Three: First Middle Last Child Three Date of Birth: MM slash DD slash YYYY Child Three if Living With: First Last Child Four: First Middle Last Child Four Date of Birth: MM slash DD slash YYYY Child Four is Living With: First Last Child Five: First Middle Last Child Five Date of Birth: MM slash DD slash YYYY Child Five is Living With: First Last Child Six: First Middle Last Child Six Date of Birth: MM slash DD slash YYYY Child Six is Living With: First Last Child Seven: First Middle Last Child Seven Date of Birth: MM slash DD slash YYYY Child Seven is Living With: First Last Child Eight: First Middle Last Child Eight Date of Birth: MM slash DD slash YYYY Child Eight is Living With: First Last Do you plan to include custody in the divorce or do you have a signed agreement which includes custody? Yes. I plan to include custody in the divorce. Yes. Custody is already stated in a signed agreement which I am requesting be incorporated in the divorce decree. Yes. There is a custody court order currently in effect but I am requesting that the terms of that order be changed. No. There is a custody court order currently in effect which I am not requesting be changed. No. There is no provision for custody in a signed agreement and no current court order and I am not requesting that custody be included. Other Do you plan to include child support in the divorce or do you have a signed agreement which includes child support? Yes. I plan to include child support. Yes. Child support is already stated in a signed agreement which I am requesting be incorporated in the divorce decree. Yes. There is a child support court order currently in effect but I am requesting that the terms of that order be changed. No. There is a child support court order currently in effect which I am not requesting be changed. No. There is no provision for child support in a signed agreement and no current court order and I am not requesting that child support be included. FinancialsDo you and your spouse have any financial assets/property to divide or debts to resolve?Including houses, cars, bank accounts, personal property, credit cards, etc. Yes No Please detail the assets below:Are you or your spouse requesting spousal support/alimony? Yes No Please detail the spousal support request:Do you or your spouse have any pension, retirement plan, 401(k) that will be divided? Yes No Please detail the retirement benefit division request:United States Armed ServicesAre you on active duty in the United States Armed Services? Yes No Is your spouse on active duty in the United States Armed Services? Yes No Status of DivorceHas a divorce case already been filed in any court by you or your spouse? Yes No Is the divorce case still open? Yes No In which court was the case filed? Client Demographic InformationClient's Place of Birth: Client's Date of Birth: MM slash DD slash YYYY Client's Education Level:Highest Level Completed Client's number of marriages:12345678Spouse Demographic InformationSpouse's Place of Birth: Spouse's Date of Birth: MM slash DD slash YYYY Spouse's Education:Highest Level Completed Spouse's number of marriages:12345678Other InformationIs there any other information that the attorney should know about your situation?Do you have any questions about the divorce procedure?EmailThis field is for validation purposes and should be left unchanged. Serving Area + Alexandria VAAnnandale VAAshburn VACentreville VAChantilly VADulles VAFairfax VAFalls Church VAHerndon VALeesburg VAMcLean VANorfolk VANorthern VirginiaOakton VAReston VARichmond VASpringfield VASterling VATysons VAVienna VAVirginia Beach VA