cportal.cordelllaw.com
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199.255.231.164
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https://cportal.cordelllaw.com/intake/IntakeForm.aspx?office=163&consult=XfgVvBD94WAQonGIknR8MDlziDgF9lPB9mwvwNrhdj48Qf3toIPmTn...
Submission: On January 27 via manual from US — Scanned from DE
Submission: On January 27 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
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value="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">
</div>
<div class="row">
<div class="col-xs-12 text-center">
<img id="logo" src="/images/MainLogo.png" alt="Cordell & Cordell, A Domestic Litigation Firm, A Partner Men Can Count On">
</div>
</div>
<div id="IntakeFormWrap">
<div class="row">
<div class="col-xs-12">
<div class="alert alert-neutral">
<strong>This form is to be completed by clients of Cordell & Cordell prior to their initial consultation. If you have not yet scheduled an initial consultation, please call 1-866-DADS-LAW to speak with a scheduling
representative.</strong>
</div>
</div>
</div>
<div id="AlertContainer" class="row hidden">
<div class="col-xs-12">
<div class="alert alert-danger">
<strong>Please correct any errors before submitting.</strong>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<div id="ClientInformationPanel" class="panel panel-default">
<div class="panel-heading"> Client Information </div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12 col-sm-4">
<div class="form-group">
<label>Date:</label>
<p id="CurrentDate" class="form-control-static">1/27/2024</p>
</div>
</div>
</div>
<div class="row">
</div>
<div class="row">
<div id="ClientAddressStreetField" class="col-xs-12 col-sm-8">
<div class="form-group">
<label for="ClientAddressStreet">Address:<span class="required-indicator">*</span></label>
<input name="ClientAddressStreet" type="text" id="ClientAddressStreet" class="form-control validate required" maxlength="50" value="163 Schonhardt St.">
<span class="help-block">Please enter your address</span>
</div>
</div>
<div id="ClientAddressZipField" class="col-xs-12 col-sm-4">
<div class="form-group">
<label for="ClientAddressZip">Zip:<span class="required-indicator">*</span></label>
<input name="ClientAddressZip" type="text" id="ClientAddressZip" class="form-control required validate" value="44883" maxlength="5">
<span class="help-block">Please enter a zip code</span>
</div>
</div>
</div>
<div class="row">
<div id="ClientAddressCityField" class="col-xs-12 col-sm-4">
<div class="form-group">
<label for="ClientAddressCity">City:<span class="required-indicator">*</span></label>
<select name="ClientAddressCity" id="ClientAddressCity" class="form-control required validate">
<option value="">- Select -</option>
<option value="Fort Seneca">Fort Seneca</option>
<option value="Ink">Ink</option>
<option selected="selected" value="Tiffin">Tiffin</option>
</select>
<span class="help-block">Please select a city</span>
<span class="info-block client-address-info hidden">Enter a valid ZIP code to view available cities</span>
</div>
</div>
<div id="ClientAddressStateField" class="col-xs-12 col-sm-4">
<div class="form-group">
<label for="ClientAddressState">State:<span class="required-indicator">*</span></label>
<select name="ClientAddressState" id="ClientAddressState" class="form-control required validate">
<option value="">- Select -</option>
<option selected="selected" value="OH">Ohio</option>
</select>
<span class="help-block">Please select a state</span>
<span class="info-block client-address-info hidden">Enter a valid ZIP code to view available states</span>
</div>
</div>
<div id="ClientAddressCountyField" class="col-xs-12 col-sm-4">
<div class="form-group">
<label for="ClientAddressCounty">County of Address:<span class="required-indicator">*</span></label>
<select name="ClientAddressCounty" id="ClientAddressCounty" class="form-control required validate">
<option value="">- Select -</option>
<option selected="selected" value="Seneca">Seneca</option>
</select>
<span class="help-block">Please select a county</span>
<span class="info-block client-address-info hidden">Enter a valid ZIP code to view available counties</span>
</div>
</div>
</div>
<div class="row">
<div id="ClientYearsAtAddressField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientYearsAtAddress">Years at Address:</label>
<select name="ClientYearsAtAddress" id="ClientYearsAtAddress" class="form-control">
<option value="">- Select -</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
<option value="32">32</option>
<option value="33">33</option>
<option value="34">34</option>
<option value="35">35</option>
<option value="36">36</option>
<option value="37">37</option>
<option value="38">38</option>
<option value="39">39</option>
<option value="40">40</option>
</select>
</div>
</div>
<div id="ClientMonthsAtAddressField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientMonthsAtAddress">Months at Address:</label>
<select name="ClientMonthsAtAddress" id="ClientMonthsAtAddress" class="form-control">
<option value="">- Select -</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
</select>
</div>
</div>
</div>
<div class="row">
<div id="CanContactField" class="col-xs-12">
<div class="form-group is-empty">
<label for="CanContact">Can you be contacted at this address?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="CanContact" id="CanContact" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
</div>
</div>
<div id="CanContactDetails" class="hidden">
<div class="row">
<div class="col-xs-12">
<p>If you selected no, please provide an alternate CONFIDENTIAL address below.</p>
</div>
</div>
<div class="row">
<div id="AlternateAddressStreetField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="AlternateAddressStreet">Alternate Address:</label>
<input name="AlternateAddressStreet" type="text" id="AlternateAddressStreet" class="form-control" maxlength="50">
</div>
</div>
<div id="AlternateAddressZipField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="AlternateAddressZip">Zip:</label>
<input name="AlternateAddressZip" type="text" id="AlternateAddressZip" class="form-control" maxlength="5">
</div>
</div>
</div>
<div class="row">
<div id="AlternateAddressCityField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="AlternateAddressCity">City:</label>
<select name="AlternateAddressCity" id="AlternateAddressCity" class="form-control">
<option value="">- Select -</option>
</select>
<span class="info-block alternate-address-info">Enter a valid ZIP code to view available cities</span>
</div>
</div>
<div id="AlternateAddressStateField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="AlternateAddressState">State:</label>
<select name="AlternateAddressState" id="AlternateAddressState" class="form-control">
<option value="">- Select -</option>
</select>
<span class="info-block alternate-address-info">Enter a valid ZIP code to view available states</span>
</div>
</div>
</div>
</div>
<div class="row">
<div id="ClientDateOfBirthField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientDateOfBirth">Date of Birth:<span class="required-indicator">*</span></label>
<input name="ClientDateOfBirth" type="date" id="ClientDateOfBirth" class="form-control datepicker required validate">
<span class="help-block required-help-block">Please select your birth date</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-date-format">(MM/DD/YYYY)</span></span>
</div>
</div>
</div>
<div class="row">
</div>
<div id="ContactInformationAlert" class="row">
<div class="col-xs-12">
<div class="alert alert-info">
<strong>Contact Information:</strong> Do NOT list a number or email address where calls or emails could be received by the other party or anyone you do not want receiving them; we STRONGLY suggest you create a new email account with
a new password for any communications with us.
</div>
</div>
</div>
<div id="ClientDoNotContactAlert" class="row">
<div class="col-xs-12">
<div class="alert alert-neutral">
<div class="form-group">
<div class="checkbox">
<label>
<input name="ClientDoNotContact" type="checkbox" id="ClientDoNotContact"> <strong class="text-uppercase">I do not wish to be contacted or provide any contact information.</strong>
</label>
</div>
</div>
</div>
</div>
</div>
<div id="ContactMethodAlert" class="row hidden">
<div class="col-xs-12">
<div class="alert alert-danger"> Please let us know how to contact you, with either a phone number or email address. </div>
</div>
</div>
<div class="row">
<div id="ClientWorkPhoneField" class="col-xs-12 col-sm-3">
<div class="form-group is-empty">
<label for="ClientWorkPhone">Work Phone:</label>
<input name="ClientWorkPhone" type="text" id="ClientWorkPhone" class="form-control contact-method validate" maxlength="50">
<div class="checkbox">
<label class="no-error">
<input name="ClientWorkPhoneDoNotContact" type="checkbox" id="ClientWorkPhoneDoNotContact"> <span class="do-not-contact-text">Do not contact</span>
</label>
</div>
</div>
</div>
<div id="ClientCellPhoneField" class="col-xs-12 col-sm-3">
<div class="form-group">
<label for="ClientCellPhone">Cell Phone:</label>
<input name="ClientCellPhone" type="text" id="ClientCellPhone" class="form-control contact-method validate" maxlength="50" value="(419) 310-1907">
<div class="checkbox">
<label class="no-error">
<input name="ClientCellPhoneDoNotContact" type="checkbox" id="ClientCellPhoneDoNotContact"> <span class="do-not-contact-text">Do not contact</span>
</label>
</div>
</div>
</div>
<div id="ClientHomePhoneField" class="col-xs-12 col-sm-3">
<div class="form-group is-empty">
<label for="ClientHomePhone">Home Phone:</label>
<input name="ClientHomePhone" type="text" id="ClientHomePhone" class="form-control contact-method validate" maxlength="50">
<div class="checkbox">
<label class="no-error">
<input name="ClientHomePhoneDoNotContact" type="checkbox" id="ClientHomePhoneDoNotContact"> <span class="do-not-contact-text">Do not contact</span>
</label>
</div>
</div>
</div>
<div id="ClientEmailField" class="col-xs-12 col-sm-3">
<div class="form-group">
<label for="ClientEmail">Email Address:</label>
<input name="ClientEmail" type="text" id="ClientEmail" class="form-control contact-method validate" maxlength="50" value="jamesbrooks79@icloud.com">
</div>
</div>
</div>
<div class="row">
</div>
<div id="ActionPendingDetails" class="hidden">
<div class="row">
</div>
</div>
<div class="row">
</div>
<div class="row">
</div>
</div>
</div>
<div id="OpposingPartyPanel" class="panel panel-default">
<div class="panel-heading"> Opposing Party </div>
<div class="panel-body">
<div class="row">
</div>
<div class="row">
<div id="OpposingAddressStreetField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="OpposingAddressStreet">Address:</label>
<input name="OpposingAddressStreet" type="text" id="OpposingAddressStreet" class="form-control" maxlength="50">
</div>
</div>
<div id="OpposingAddressZipField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingAddressZip">Zip:</label>
<input name="OpposingAddressZip" type="text" id="OpposingAddressZip" class="form-control" maxlength="5">
</div>
</div>
</div>
<div class="row">
<div id="OpposingAddressCityField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingAddressCity">City:</label>
<select name="OpposingAddressCity" id="OpposingAddressCity" class="form-control">
<option value="">- Select -</option>
</select>
<span class="info-block opposing-address-info">Enter a valid ZIP code to view available cities</span>
</div>
</div>
<div id="OpposingAddressStateField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingAddressState">State:</label>
<select name="OpposingAddressState" id="OpposingAddressState" class="form-control">
<option value="">- Select -</option>
</select>
<span class="info-block opposing-address-info">Enter a valid ZIP code to view available states</span>
</div>
</div>
<div id="OpposingAddressCountyField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingAddressCounty">County of Address:</label>
<select name="OpposingAddressCounty" id="OpposingAddressCounty" class="form-control">
<option value="">- Select -</option>
</select>
<span class="info-block opposing-address-info">Enter a valid ZIP code to view available counties</span>
</div>
</div>
</div>
<div class="row">
<div id="IsOpposingDurationAtAddressKnownField" class="col-xs-12">
<div class="form-group is-empty">
<label for="IsOpposingDurationAtAddressKnown">Do you know how long the opposing party has been at this address?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="IsOpposingDurationAtAddressKnown" id="IsOpposingDurationAtAddressKnown" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="IsOpposingDurationAtAddressKnownDetails" class="hidden">
<div class="row">
<div id="OpposingYearsAtAddressField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingYearsAtAddress">Years at Address:</label>
<select name="OpposingYearsAtAddress" id="OpposingYearsAtAddress" class="form-control">
<option value="">- Select -</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
<option value="32">32</option>
<option value="33">33</option>
<option value="34">34</option>
<option value="35">35</option>
<option value="36">36</option>
<option value="37">37</option>
<option value="38">38</option>
<option value="39">39</option>
<option value="40">40</option>
</select>
</div>
</div>
<div id="OpposingMonthsAtAddressField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingMonthsAtAddress">Months at Address:</label>
<select name="OpposingMonthsAtAddress" id="OpposingMonthsAtAddress" class="form-control">
<option value="">- Select -</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
</select>
</div>
</div>
</div>
</div>
<div class="row">
</div>
<div class="row">
</div>
</div>
</div>
<div id="RacePanel" class="panel panel-default">
<div class="panel-heading"> Ethnicity </div>
<div class="panel-body">
<div class="row">
<div id="ClientRaceField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientRace">Client Ethnicity:</label>
<select name="ClientRace" id="ClientRace" class="form-control">
<option value="">- Select -</option>
<option value="American Indian or Alaska Native">American Indian or Alaska Native</option>
<option value="Asian">Asian</option>
<option value="Black or African American">Black or African American</option>
<option value="Hispanic or Latino">Hispanic or Latino</option>
<option value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</option>
<option value="White">White</option>
<option value="Two or More Races">Two or More Races</option>
<option value="Declined to Self-Identify">Declined to Self-Identify</option>
</select>
</div>
</div>
<div id="OpposingRaceField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingRace">Opposing Party Ethnicity:</label>
<select name="OpposingRace" id="OpposingRace" class="form-control">
<option value="">- Select -</option>
<option value="American Indian or Alaska Native">American Indian or Alaska Native</option>
<option value="Asian">Asian</option>
<option value="Black or African American">Black or African American</option>
<option value="Hispanic or Latino">Hispanic or Latino</option>
<option value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</option>
<option value="White">White</option>
<option value="Two or More Races">Two or More Races</option>
<option value="Declined to Self-Identify">Declined to Self-Identify</option>
</select>
</div>
</div>
</div>
</div>
</div>
<div id="ClientEmploymentPanel" class="panel panel-default">
<div class="panel-heading"> Client Employment </div>
<div class="panel-body">
<div class="row">
<div id="ClientCurrentlyEmployedField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientCurrentlyEmployed">Are you employed?<span class="required-indicator">*</span></label>
<select name="ClientCurrentlyEmployed" id="ClientCurrentlyEmployed" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="Retired">Retired</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
<div id="ClientSalaryRangeField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientSalaryRange">Salary Range:<span class="required-indicator">*</span></label>
<select name="ClientSalaryRange" id="ClientSalaryRange" class="form-control required validate">
<option value="">- Select -</option>
<option value="8">$0-$20,000</option>
<option value="9">$20,001-$30,000</option>
<option value="10">$30,001-$40,000</option>
<option value="11">$40,001-$50,000</option>
<option value="12">$50,001-$60,000</option>
<option value="13">$60,001-$70,000</option>
<option value="14">$70,001-$80,000</option>
<option value="15">$80,001-$90,000</option>
<option value="16">$90,001-$100,000</option>
<option value="17">$100,001-$125,000</option>
<option value="18">$125,001-$150,000</option>
<option value="19">$150,001-$200,000</option>
<option value="20">$200,001+</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="ClientCurrentlyEmployedDetails" class="hidden">
<div class="row">
<div id="ClientEmployerNameField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientEmployerName">Name of employer:<span class="required-indicator">*</span></label>
<input name="ClientEmployerName" type="text" id="ClientEmployerName" class="form-control required validate" maxlength="100">
<span class="help-block">Please provide an employer name</span>
</div>
</div>
<div id="ClientEmployedSinceField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientEmployedSince">Employed Since:<span class="required-indicator">*</span></label>
<input name="ClientEmployedSince" type="month" id="ClientEmployedSince" class="form-control monthpicker required validate">
<span class="help-block required-help-block">Please make a selection</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-month-format">(MM/DD/YYYY)</span></span>
</div>
</div>
</div>
<div class="row">
<div id="ClientOccupationField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="ClientOccupation">Occupation:<span class="required-indicator">*</span></label>
<select name="ClientOccupation" id="ClientOccupation" class="form-control required validate">
<option value="">- Select -</option>
<option value="1">Contract</option>
<option value="2">Education</option>
<option value="3">Entrepreneur/Self-Employed</option>
<option value="4">Food & Hospitality</option>
<option value="5">Franchise</option>
<option value="6">Government/Healthcare</option>
<option value="7">Information Technology</option>
<option value="8">Legal Services</option>
<option value="9">Manufacturing</option>
<option value="10">Media/Communication</option>
<option value="11">Nonprofit</option>
<option value="12">Professional Services (Accounting, Real Estate, Insurance, Finance)</option>
<option value="13">Retail</option>
<option value="14">Science & Biotech</option>
<option value="15">Skilled Labor/Trade</option>
<option value="16">Student</option>
<option value="17">Transportation</option>
<option value="18">Unemployed</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
<div id="ClientJobTitleField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientJobTitle">Job Title:</label>
<input name="ClientJobTitle" type="text" id="ClientJobTitle" class="form-control" maxlength="50">
</div>
</div>
</div>
</div>
<div id="ClientCurrentlyUnemployedDetails">
<div class="row">
<div id="ClientLastJobDateField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientLastJobDate">If unemployed, date of last job:</label>
<input name="ClientLastJobDate" type="month" id="ClientLastJobDate" class="form-control monthpicker conditionally-required validate">
<span class="help-block required-help-block">Please make a selection</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-month-format">(MM/YYYY)</span></span>
</div>
</div>
</div>
</div>
<div class="row">
</div>
</div>
</div>
<div id="EmploymentOfOpposingPartyPanel" class="panel panel-default">
<div class="panel-heading"> Opposing Party Employment </div>
<div class="panel-body">
<div class="row">
<div id="OpposingCurrentlyEmployedField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingCurrentlyEmployed">Is the opposing party employed?<span class="required-indicator">*</span></label>
<select name="OpposingCurrentlyEmployed" id="OpposingCurrentlyEmployed" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="Retired">Retired</option>
<option value="U">Unknown</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
<div id="OpposingSalaryRangeField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingSalaryRange">Salary Range:</label>
<select name="OpposingSalaryRange" id="OpposingSalaryRange" class="form-control">
<option value="">- Select -</option>
<option value="8">$0-$20,000</option>
<option value="9">$20,001-$30,000</option>
<option value="10">$30,001-$40,000</option>
<option value="11">$40,001-$50,000</option>
<option value="12">$50,001-$60,000</option>
<option value="13">$60,001-$70,000</option>
<option value="14">$70,001-$80,000</option>
<option value="15">$80,001-$90,000</option>
<option value="16">$90,001-$100,000</option>
<option value="17">$100,001-$125,000</option>
<option value="18">$125,001-$150,000</option>
<option value="19">$150,001-$200,000</option>
<option value="20">$200,001+</option>
</select>
</div>
</div>
</div>
<div id="OpposingCurrentlyEmployedDetails" class="hidden">
<div class="row">
<div id="OpposingEmployerNameField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingEmployerName">Name of employer:<span class="required-indicator">*</span></label>
<input name="OpposingEmployerName" type="text" id="OpposingEmployerName" class="form-control required validate">
<span class="help-block">Please provide an employer name</span>
</div>
</div>
<div id="IsOpposingEmployedSinceKnownField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="IsOpposingEmployedSinceKnown">Do you know when the opposing party was hired?</label>
<div class="row">
<div class="col-xs-12 col-sm-6">
<select name="IsOpposingEmployedSinceKnown" id="IsOpposingEmployedSinceKnown" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="IsOpposingEmployedSinceKnownDetails" class="hidden">
<div class="row">
<div id="OpposingEmployedSinceField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingEmployedSince">Employed Since:<span class="required-indicator">*</span></label>
<input name="OpposingEmployedSince" type="month" id="OpposingEmployedSince" class="form-control required validate monthpicker">
<span class="help-block required-help-block">Please make a selection</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-month-format">(MM/YYYY)</span></span>
</div>
</div>
</div>
</div>
<div class="row">
<div id="OpposingOccupationField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="OpposingOccupation">Occupation:<span class="required-indicator">*</span></label>
<select name="OpposingOccupation" id="OpposingOccupation" class="form-control required validate">
<option value="">- Select -</option>
<option value="1">Contract</option>
<option value="2">Education</option>
<option value="3">Entrepreneur/Self-Employed</option>
<option value="4">Food & Hospitality</option>
<option value="5">Franchise</option>
<option value="6">Government/Healthcare</option>
<option value="7">Information Technology</option>
<option value="8">Legal Services</option>
<option value="9">Manufacturing</option>
<option value="10">Media/Communication</option>
<option value="11">Nonprofit</option>
<option value="12">Professional Services (Accounting, Real Estate, Insurance, Finance)</option>
<option value="13">Retail</option>
<option value="14">Science & Biotech</option>
<option value="15">Skilled Labor/Trade</option>
<option value="16">Student</option>
<option value="17">Transportation</option>
<option value="18">Unemployed</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
<div id="OpposingJobTitleField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingJobTitle">Job Title:</label>
<input name="OpposingJobTitle" type="text" id="OpposingJobTitle" class="form-control">
</div>
</div>
</div>
</div>
<div id="OpposingCurrentlyUnemployedDetails">
<div class="row">
<div id="OpposingLastJobDateField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingLastJobDate">If unemployed, date of last job:</label>
<input name="OpposingLastJobDate" type="month" id="OpposingLastJobDate" class="form-control monthpicker conditionally-required validate">
<span class="help-block required-help-block">Please make a selection</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-month-format">(MM/YYYY)</span></span>
</div>
</div>
</div>
</div>
<div class="row">
</div>
</div>
</div>
</div>
<div class="col-xs-12">
<div id="MarriageHistoryPanel" class="panel panel-default">
<div class="panel-heading"> Marriage History </div>
<div class="panel-body">
<div class="row">
<div id="MarriedToOpposingField" class="col-xs-12">
<div class="form-group is-empty">
<label for="MarriedToOpposing">What is your current relationship with the opposing party?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="MarriedToOpposing" id="MarriedToOpposing" class="form-control required validate">
<option value="">- Select -</option>
<option value="N">Never Married</option>
<option value="Y">Currently Married</option>
<option value="D">Divorced</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="MarriedToOrDivorcedFromOpposingDetails" class="hidden">
<div class="row">
<div id="IsDateOfMarriageKnownField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="IsDateOfMarriageKnown">Do you know the date of marriage?<span class="required-indicator">*</span></label>
<select name="IsDateOfMarriageKnown" id="IsDateOfMarriageKnown" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
<div id="DateOfMarriageField" class="col-xs-12 col-sm-4 hidden">
<div class="form-group is-empty">
<label for="DateOfMarriage">Date of Marriage:<span class="required-indicator">*</span></label>
<input name="DateOfMarriage" type="date" id="DateOfMarriage" class="form-control datepicker required validate">
<span class="help-block required-help-block">Please enter the date of marriage</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-date-format">(MM/DD/YYYY)</span></span>
</div>
</div>
</div>
</div>
<div id="MarriedToOpposingDetails" class="hidden">
<div class="row">
<div id="SeparatedFromOpposingField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="SeparatedFromOpposing">Are you legally separated?<span class="required-indicator">*</span></label>
<select name="SeparatedFromOpposing" id="SeparatedFromOpposing" class="form-control required validate">
<option value="">- Select - </option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
</div>
<div id="SeparatedFromOpposingDetails" class="hidden">
<div class="row">
<div id="DateOfSeparationField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="DateOfSeparation">Date of Separation:<span class="required-indicator">*</span></label>
<input name="DateOfSeparation" type="date" id="DateOfSeparation" class="form-control datepicker required validate">
<span class="help-block required-help-block">Please enter the date of separation</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-date-format">(MM/DD/YYYY)</span></span>
</div>
</div>
</div>
</div>
<div id="DivorcedFromOpposingDetails" class="hidden">
<div class="row">
<div id="DateOfDivorceField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="DateOfDivorce">Date of Divorce:<span class="required-indicator">*</span></label>
<input name="DateOfDivorce" type="date" id="DateOfDivorce" class="form-control datepicker required validate">
<span class="help-block required-help-block">Please enter the date of divorce</span>
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-date-format">(MM/DD/YYYY)</span></span>
</div>
</div>
</div>
</div>
<div id="MarriedToOrNeverMarriedToOpposingDetails" class="hidden">
<div class="row">
<div id="LivingWithSpouseField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="LivingWithSpouse">Are you and the opposing party living together?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-6">
<select name="LivingWithSpouse" id="LivingWithSpouse" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
</div>
<div class="row">
</div>
<div id="MarriageLocationDetails" class="hidden">
<div class="row">
</div>
<div class="row">
</div>
<div id="MarriageCountryDetails" class="row">
</div>
</div>
</div>
</div>
<div id="ClientChildrenPanel" class="panel panel-default">
<div class="panel-heading"> Children </div>
<div class="panel-body">
<div class="row">
<div id="MinorChildrenInvolvedField" class="col-xs-12">
<div class="form-group is-empty">
<label for="MinorChildrenInvolved">Are minor children involved?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="MinorChildrenInvolved" id="MinorChildrenInvolved" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="MinorChildrenInvolvedDetails" class="hidden">
<div class="row">
<div id="NumberOfChildrenWithOpposingField" class="col-xs-12">
<div class="form-group is-empty">
<label for="NumberOfChildrenWithOpposing">How many children do you have with the opposing party?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="NumberOfChildrenWithOpposing" id="NumberOfChildrenWithOpposing" class="form-control required validate">
<option value="">- Select -</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="NumberOfChildrenWithOpposingDetails" class="hidden">
</div>
<div class="row">
<div id="OtherChildrenInvolvedField" class="col-xs-12">
<div class="form-group is-empty">
<label for="OtherChildrenInvolved">Are there other children involved outside this case?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="OtherChildrenInvolved" id="OtherChildrenInvolved" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
</div>
</div>
<div id="OtherChildrenInvolvedDetails" class="hidden">
<div class="row">
<div id="NumberOfChildrenWithOtherField" class="col-xs-12">
<div class="form-group is-empty">
<label for="NumberOfChildrenWithOther">How many other children do you have?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="NumberOfChildrenWithOther" id="NumberOfChildrenWithOther" class="form-control required validate">
<option value="">- Select -</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="NumberOfChildrenWithOtherDetails" class="hidden">
</div>
</div>
</div>
</div>
<div id="ChildDetailsTemplate" class="hidden row child-details">
<div class="col-xs-12">
<div class="panel panel-primary">
<div class="panel-heading"> </div>
<div class="panel-body">
<div class="row">
<div id="ChildFirstNameField" class="col-xs-12 col-sm-1-5">
<div class="form-group is-empty">
<label>Name<span class="required-indicator">*</span></label>
<input name="ChildFirstName" type="text" id="ChildFirstName" class="form-control required validate" maxlength="50">
<span class="help-block">Please enter a name</span>
</div>
</div>
<div id="ChildAgeField" class="col-xs-12 col-sm-1-5">
<div class="form-group is-empty">
<label>Age of Child<span class="required-indicator">*</span></label>
<input name="ChildAge" type="number" id="ChildAge" class="form-control required validate number">
<span class="help-block">Please enter an age</span>
</div>
</div>
<div id="ChildLivesWithField" class="col-xs-12 col-sm-1-5">
<div class="form-group is-empty">
<label>Living With<span class="required-indicator">*</span></label>
<select name="ChildLivesWith" id="ChildLivesWith" class="form-control required validate">
<option value="">- Select -</option>
<option value="Father">Father</option>
<option value="Mother">Mother</option>
<option value="Both">Both</option>
<option value="Paternal Grandparent">Paternal Grandparent</option>
<option value="Maternal Grandparent">Maternal Grandparent</option>
<option value="Other Relative">Other Relative</option>
<option value="Non Relative">Non Relative</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div id="EducationPanel" class="panel panel-default">
<div class="panel-heading"> Education </div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<p>Please list below the highest level of education/training for you and the opposing party:</p>
</div>
</div>
<div class="row">
<div id="ClientEducationField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="ClientEducation">You:<span class="required-indicator">*</span></label>
<select name="ClientEducation" id="ClientEducation" class="form-control required validate">
<option value="">- Select -</option>
<option value="Grade School">Grade School</option>
<option value="High School">High School</option>
<option value="GED">GED</option>
<option value="Vocational">Vocational</option>
<option value="College">College</option>
<option value="Post Graduate">Post Graduate</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div class="row">
<div id="OpposingEducationField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="OpposingEducation">Opposing Party:<span class="required-indicator">*</span></label>
<select name="OpposingEducation" id="OpposingEducation" class="form-control required validate">
<option value="">- Select -</option>
<option value="Grade School">Grade School</option>
<option value="High School">High School</option>
<option value="GED">GED</option>
<option value="Vocational">Vocational</option>
<option value="College">College</option>
<option value="Post Graduate">Post Graduate</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
</div>
</div>
<div id="OtherPanel" class="panel panel-default">
<div class="panel-heading"> Other </div>
<div class="panel-body">
<div class="row">
<div id="LastCourtModificationDateField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="LastCourtModificationDate">Last Modification of Judgement:</label>
<input name="LastCourtModificationDate" type="date" id="LastCourtModificationDate" class="form-control datepicker validate">
<span class="help-block format-help-block">Input date is in an invalid format <span class="valid-date-format">(MM/DD/YYYY)</span></span>
</div>
</div>
</div>
<div class="row">
<div id="HasOpposingConsultedAttorneyField" class="col-xs-12">
<div class="form-group is-empty">
<label for="HasOpposingConsultedAttorney">Has the opposing party consulted an attorney regarding this matter?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="HasOpposingConsultedAttorney" id="HasOpposingConsultedAttorney" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="U">Unknown</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="HasOpposingConsultedAttorneyDetails" class="hidden">
<div class="row">
<div id="OpposingAttorneyNameField" class="col-xs-12 col-sm-6">
<div class="form-group is-empty">
<label for="OpposingAttorneyName">Name of an attorney, if known:</label>
<input name="OpposingAttorneyName" type="text" id="OpposingAttorneyName" class="form-control" maxlength="50">
</div>
</div>
<div id="OpposingAttorneyAddressField" class="col-xs-12 col-sm-6">
<div class="form-group is-empty">
<label for="OpposingAttorneyAddress">Address of an attorney, if known:</label>
<input name="OpposingAttorneyAddress" type="text" id="OpposingAttorneyAddress" class="form-control" maxlength="1000">
</div>
</div>
</div>
</div>
<div class="row">
<div id="SignedPapersField" class="col-xs-12">
<div class="form-group is-empty">
<label for="SignedPapers">Have you signed anything which may affect this case, including prenuptial or postnuptial agreement(s), or other documents presented by your spouse?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-8">
<select name="SignedPapers" id="SignedPapers" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="U">Unknown</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="SignedPapersDetails" class="hidden">
<div class="row">
<div id="SignedPapersDescriptionField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="SignedPapersDescription">If so, please describe the document:</label>
<input name="SignedPapersDescription" type="text" id="SignedPapersDescription" class="form-control">
</div>
</div>
</div>
</div>
<div class="row">
<div id="PendingPersonalInjuryField" class="col-xs-12">
<div class="form-group is-empty">
<label for="PendingPersonalInjury">Are there any potential/pending personal injury/worker compensation claims?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="PendingPersonalInjury" id="PendingPersonalInjury" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="U">Unknown</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div class="row">
<div id="ExistingCourtOrdersField" class="col-xs-12">
<div class="form-group is-empty">
<label for="ExistingCourtOrders">Are there any existing Court or Administrative Orders with this opposing party?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="ExistingCourtOrders" id="ExistingCourtOrders" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="U">Unknown</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div id="ExistingCourtOrdersDetails" class="hidden">
<div class="row">
<div id="ExistingCourtOrdersDescriptionField" class="col-xs-12">
<div class="form-group is-empty">
<label for="ExistingCourtOrdersDescription">If so, can you please describe the court or administrative orders?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-8">
<input name="ExistingCourtOrdersDescription" type="text" id="ExistingCourtOrdersDescription" class="form-control required validate">
</div>
</div>
<span class="help-block">Please describe the court order</span>
</div>
</div>
</div>
</div>
<div class="row">
<div id="CitizenField" class="col-xs-12 col-sm-4">
<div class="form-group is-empty">
<label for="Citizen">Are you a US Citizen?<span class="required-indicator">*</span></label>
<select name="Citizen" id="Citizen" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
<span class="help-block">Please make a selection</span>
</div>
</div>
<div id="OpposingCitizenField" class="col-xs-12 col-sm-8">
<div class="form-group is-empty">
<label for="OpposingCitizen">Is the opposing party a US Citizen?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-6">
<select name="OpposingCitizen" id="OpposingCitizen" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
<option value="U">Unknown</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div class="row">
<div id="ArmedForcesField" class="col-xs-12">
<div class="form-group is-empty">
<label for="ArmedForces">Are you a member of the Armed Forces of the United States on active duty?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="ArmedForces" id="ArmedForces" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div class="row">
<div id="OpposingArmedForcesField" class="col-xs-12">
<div class="form-group is-empty">
<label for="OpposingArmedForces">Is the opposing party a member of the Armed Forces of the United States on active duty?<span class="required-indicator">*</span></label>
<div class="row">
<div class="col-xs-12 col-sm-4">
<select name="OpposingArmedForces" id="OpposingArmedForces" class="form-control required validate">
<option value="">- Select -</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</div>
</div>
<span class="help-block">Please make a selection</span>
</div>
</div>
</div>
<div class="row">
</div>
<div id="OnSocialNetworksDetails" class="hidden">
<div class="row">
</div>
</div>
<div class="row">
</div>
<div id="OpposingOnSocialNetworksDetails" class="hidden">
<div class="row">
</div>
</div>
<div class="row">
</div>
</div>
</div>
<div class="panel panel-default">
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<button type="submit" id="SubmitButton" class="btn btn-success btn-block"> Submit </button>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</form>Text Content
This form is to be completed by clients of Cordell & Cordell prior to their initial consultation. If you have not yet scheduled an initial consultation, please call 1-866-DADS-LAW to speak with a scheduling representative. Please correct any errors before submitting. Client Information Date: 1/27/2024 Address:* Please enter your address Zip:* Please enter a zip code City:* - Select - Fort Seneca Ink Tiffin Please select a city Enter a valid ZIP code to view available cities State:* - Select - Ohio Please select a state Enter a valid ZIP code to view available states County of Address:* - Select - Seneca Please select a county Enter a valid ZIP code to view available counties Years at Address: - Select - 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Months at Address: - Select - 0 1 2 3 4 5 6 7 8 9 10 11 Can you be contacted at this address?* - Select - Yes No Please make a selection If you selected no, please provide an alternate CONFIDENTIAL address below. Alternate Address: Zip: City: - Select - Enter a valid ZIP code to view available cities State: - Select - Enter a valid ZIP code to view available states Date of Birth:* Please select your birth date Input date is in an invalid format (MM/DD/YYYY) Contact Information: Do NOT list a number or email address where calls or emails could be received by the other party or anyone you do not want receiving them; we STRONGLY suggest you create a new email account with a new password for any communications with us. I do not wish to be contacted or provide any contact information. Please let us know how to contact you, with either a phone number or email address. Work Phone: Do not contact Cell Phone: Do not contact Home Phone: Do not contact Email Address: Opposing Party Address: Zip: City: - Select - Enter a valid ZIP code to view available cities State: - Select - Enter a valid ZIP code to view available states County of Address: - Select - Enter a valid ZIP code to view available counties Do you know how long the opposing party has been at this address?* - Select - Yes No Please make a selection Years at Address: - Select - 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Months at Address: - Select - 0 1 2 3 4 5 6 7 8 9 10 11 Ethnicity Client Ethnicity: - Select - American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races Declined to Self-Identify Opposing Party Ethnicity: - Select - American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races Declined to Self-Identify Client Employment Are you employed?* - Select - Yes No Retired Please make a selection Salary Range:* - Select - $0-$20,000 $20,001-$30,000 $30,001-$40,000 $40,001-$50,000 $50,001-$60,000 $60,001-$70,000 $70,001-$80,000 $80,001-$90,000 $90,001-$100,000 $100,001-$125,000 $125,001-$150,000 $150,001-$200,000 $200,001+ Please make a selection Name of employer:* Please provide an employer name Employed Since:* Please make a selection Input date is in an invalid format (MM/DD/YYYY) Occupation:* - Select - Contract Education Entrepreneur/Self-Employed Food & Hospitality Franchise Government/Healthcare Information Technology Legal Services Manufacturing Media/Communication Nonprofit Professional Services (Accounting, Real Estate, Insurance, Finance) Retail Science & Biotech Skilled Labor/Trade Student Transportation Unemployed Please make a selection Job Title: If unemployed, date of last job: Please make a selection Input date is in an invalid format (MM/YYYY) Opposing Party Employment Is the opposing party employed?* - Select - Yes No Retired Unknown Please make a selection Salary Range: - Select - $0-$20,000 $20,001-$30,000 $30,001-$40,000 $40,001-$50,000 $50,001-$60,000 $60,001-$70,000 $70,001-$80,000 $80,001-$90,000 $90,001-$100,000 $100,001-$125,000 $125,001-$150,000 $150,001-$200,000 $200,001+ Name of employer:* Please provide an employer name Do you know when the opposing party was hired? - Select - Yes No Please make a selection Employed Since:* Please make a selection Input date is in an invalid format (MM/YYYY) Occupation:* - Select - Contract Education Entrepreneur/Self-Employed Food & Hospitality Franchise Government/Healthcare Information Technology Legal Services Manufacturing Media/Communication Nonprofit Professional Services (Accounting, Real Estate, Insurance, Finance) Retail Science & Biotech Skilled Labor/Trade Student Transportation Unemployed Please make a selection Job Title: If unemployed, date of last job: Please make a selection Input date is in an invalid format (MM/YYYY) Marriage History What is your current relationship with the opposing party?* - Select - Never Married Currently Married Divorced Please make a selection Do you know the date of marriage?* - Select - Yes No Please make a selection Date of Marriage:* Please enter the date of marriage Input date is in an invalid format (MM/DD/YYYY) Are you legally separated?* - Select - Yes No Please make a selection Date of Separation:* Please enter the date of separation Input date is in an invalid format (MM/DD/YYYY) Date of Divorce:* Please enter the date of divorce Input date is in an invalid format (MM/DD/YYYY) Are you and the opposing party living together?* - Select - Yes No Please make a selection Children Are minor children involved?* - Select - Yes No Please make a selection How many children do you have with the opposing party?* - Select - 0 1 2 3 4 5 6 7 8 9 10 Please make a selection Are there other children involved outside this case?* - Select - Yes No Please make a selection How many other children do you have?* - Select - 0 1 2 3 4 5 6 7 8 9 10 Please make a selection Name* Please enter a name Age of Child* Please enter an age Living With* - Select - Father Mother Both Paternal Grandparent Maternal Grandparent Other Relative Non Relative Please make a selection Education Please list below the highest level of education/training for you and the opposing party: You:* - Select - Grade School High School GED Vocational College Post Graduate Please make a selection Opposing Party:* - Select - Grade School High School GED Vocational College Post Graduate Please make a selection Other Last Modification of Judgement: Input date is in an invalid format (MM/DD/YYYY) Has the opposing party consulted an attorney regarding this matter?* - Select - Yes No Unknown Please make a selection Name of an attorney, if known: Address of an attorney, if known: Have you signed anything which may affect this case, including prenuptial or postnuptial agreement(s), or other documents presented by your spouse?* - Select - Yes No Unknown Please make a selection If so, please describe the document: Are there any potential/pending personal injury/worker compensation claims?* - Select - Yes No Unknown Please make a selection Are there any existing Court or Administrative Orders with this opposing party?* - Select - Yes No Unknown Please make a selection If so, can you please describe the court or administrative orders?* Please describe the court order Are you a US Citizen?* - Select - Yes No Please make a selection Is the opposing party a US Citizen?* - Select - Yes No Unknown Please make a selection Are you a member of the Armed Forces of the United States on active duty?* - Select - Yes No Please make a selection Is the opposing party a member of the Armed Forces of the United States on active duty?* - Select - Yes No Please make a selection Submit