*compulsory field

Personal details

Title: Select Mr Miss Mrs Ms *Surname:

Middle Name: *First Name:

Date of Birth: (dd / mm / yyyy) Birthplace:

Postal Address

*Street: *City / Suburb:

*State: *Post Code:

Home Address

Street: (if same as postal write 'as above')

City / Suburb: State: Post Code:

Do you wish mail to be posted to your home?: Select yes no

Phone

*Home: Work: Mobile:

Fax: Please contact me on: Select Home phone Work phone Mobile phone via Fax via Email

*Email:

Cohabitation

Date Commenced: If Relevant - Date Ceased / Separation:

Date of Marriage / Date of Divorce:

Employment

Occupation: Employer Name:

Gross Income

Current Wage: Salary:

Own Business: Pension:

Spouse / Partner Details

Full Name:

Address:

City / Suburb: State: Post Code:

Contact Details:

Wage / Salary:

Solicitor: (if applicable)

Child Details

Child 1

Name: Date of Birth: (dd / mm / yyyy)

Person with whom they live: Select Mother Father Other If Other Please State:

Health: Select good poor Educational Institution:

Address:

City/Suburb:

State: Post Code:

Contact Details: Is Child Support Being Paid? Selected yes no occasionally

Child 2

Name: Date of Birth: (dd / mm / yyyy)

Person with whom they live: Select Mother Father Other If Other Please State:

Health: Select good poor Educational institution:

Address:

City / Suburb:

State: Post Code:

Contact Details: Is Child Support Being Paid? Select yes no occasionally

Other Children

Details of other children living with you

Domestic Violence

Any Domestic Violence Orders?
N/A pending In Existence Alternate Dispute Resolution attendances - mediataion Counselling Other

if other, please specify:

Assets

Value of matrimonial home: $ Obtain recent market appraisal

Value of other Real Estate: $ Obtain recent market appraisal

Motor Vehicles:

Owned By:

Current Value - each: $   Insured Value - each: $

Registration Numbers: 

Person in whose name the car is registered:

Other Assets:

Shares:

(specify no. shares, companies and their current value)

Investments:

(specify all relevant info)

Credit in Savings Accounts:

date of seperation:$   now:$

Boat/Caravan/Stamp or other Collection: (if applicable)

Goods and Chattels if Sold at Auction: (if applicable)

Interest in Trusts: (if applicable)

Life Assurance Policies: (if applicable)

Liabilities

Mortgages and other encumbrances associated with the property:

(specify bank and amount owing) Other Debts:

Car Loans - amount: $

Personal Loans - amount: $

Credit Card - amount: $

Financial Resources:

Superannuation Details: Current Value   Years Contributed

Inheritances Due

Comcare / Personal Injury Payouts

Other:

Contributions:

At the commencement of the relationship, what did you bring in?

What did your partner bring in?

During the relationship, what did you contribute other than your normal salary or income?

Inheritance - value

Injury Payout - value

Comcare - value

Gifts for the Family - value Other - Specify below

(include any non-financial contributions as well as financial contributions. eg caring for a sick partner/parent/child, building the matrimonial home, etc)

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