Form - Premier Life Solutions

INFORMATION ABOUT THE PLAINTIFF (YOU):
PLAINTIFF’S Name: (TYPE NAME EXACTLY AS IT APPEARS ON YOUR DRIVER'S LICENSE/PASSPORT)*
Gender*
- Male
- Female
What Was Your Full Name at Birth?*
Address:*
City:*
State:*
Zip:*
County of Residence*
Date of birth:*
Date Format: MM slash DD slash YYYY
STATE of Birth*
Social Security #*
Phone Number :*
PLAINTIFF’s Gross Annual Income $
( If blank, we will use $0 as PLAINTIFF’s gross annual income)
PLAINTIFF’s NYC/Yonkers Tax Paid $
( If blank, we will use $0 as PLAINTIFF’s NYC/Yonkers Tax Paid )
PLAINTIFF’S CONFIDENTIAL INFORMATION:
PLAINTIFF’s Race?*
- White
- Black
- Hispanic
- Asian
- Other
# of This Marriage For PLAINTIFF: (1st , 2nd , etc.)?*
- First
- Second
- Third
- Fourth
- Fifth
If Previously Married How Many Ended by Death?*
- None
- One
- Two
- Three
- Four
If Previously Married How Many Ended by Divorce?*
- None
- One
- Two
- Three
- Four
PLAINTIFF Highest Grade Level Completed:
Pick Your Highest Grade Completed*

PLAINTIFF’S INFORMATION: [DRL § 240 1 (a-1) and DRL § 240 1 (a)]
- PLAINTIFF & THE KIDS HAVE NEVER BEEN NAMED IN AN ORDER OF PROTECTION
- PLAINTIFF & THE KIDS HAVE NOT BEEN NAMED IN A CHILD ABUSE/NEGLECT CASE
- PLAINTIFF IS NOT REGISTERED UNDER NY SEX OFFENDER REGISTRATION ACT
☞ COMPLETE THE SECTION(S) BELOW ONLY IF NEEDED
DO YOU HAVE AN ORDER OF PROTECTION? (IF YES, FILL OUT FORM BELOW)*
- YES
- NO
ORDERS OF PROTECTION (OOP) - PLAINTIFF
- An OOP has been issued AGAINST PLAINTIFF (PLAINTIFF has been ordered to keep away from someone).
List all Family/Criminal Court Docket #’s and Counties:
List all Supreme Court Index #’s and Counties:
OR
- An OOP has been issued PROTECTING PLAINTIFF and or the child(ren) from someone else.
List all Family/Criminal Court Docket #’s and Counties:
List all Family/Criminal Court Docket #’s and Counties:
CHILD ABUSE/NEGLECT PROCEEDINGS
- PLAINTIFF OR THE CHILDREN have been a party in a Child Abuse/Neglect Proceeding (FCA Art.10)
List all Family Court Docket #’s
and Counties
NEW YORK STATE’S SEX OFFENDER REGISTRATION ACT
- PLAINTIFF IS registered under New York State’s Sex Offender Registration Act
List all names under which PLAINTIFF is registered

DEFENDANT’S INFORMATION: [DRL § 240 1 (a-1) and DRL § 240 1 (a)]
- DEFENDANT & THE KIDS HAVE NEVER BEEN NAMED IN AN ORDER OF PROTECTION
- DEFENDANT & THE KIDS HAVE NOT BEEN NAMED IN A CHILD ABUSE/NEGLECT CASE
- DEFENDANT IS NOT REGISTERED UNDER NY SEX OFFENDER REGISTRATION ACT
ORDERS OF PROTECTION (OOP) - DEFENDANT
- An OOP has been issued AGAINST DEFENDANT and Def. has been ordered to keep away from someone).
List all Family/Criminal Court Docket #’s and Counties:
List all Supreme Court Index #’s and Counties:
OR
- An OOP has been issued PROTECTING DEFENDANT and or the child(ren) from someone else
List all Family/Criminal Court Docket #’s and Counties:
List all Supreme Court Index #’s and Counties:
CHILD ABUSE/NEGLECT PROCEEDINGS
- DEFENDANT OR THE CHILDREN have been a party in a Child Abuse/Neglect Proceeding (FCA Art.10)
List all Family Court Docket #’s
and Counties
NEW YORK STATE’S SEX OFFENDER REGISTRATION ACT
- DEFENDANT IS registered under New York State’s Sex Offender Registration Act
List all names under which DEFENDANT is registered*

IMPORTANT QUESTIONS ABOUT FAMILY COURT!
Are the parties currently involved in any pending family court litigation about custody, visitation, child support, or spousal maintenance?*
- Yes
- No
1. If NO - SKIP to the next box! 2. If YES - If the parties are currently involved in any family litigation about custody, visitation, child support or maintenance, please answer the following questions:
COUNTY WHERE FAMILY COURT ACTION IS PENDING?
DOCKET NUMBER(S) OF ALL PENDING CASES?
ISSUES BEING LITIGATED?
- Custody
- Visitation
- Child Support
- Alimony
- Other
PRE-EXISTING AGREEMENTS - PLEASE READ!
PRE-EXISTING AGREEMENTS

- If the parties currently have a valid current agreement like a Separation Agreement or Stipulation of Settlement and the parties do not want to change or amend their current existing agreement, STOP here. Please attach a signed and notarized copy of the existing agreement to this intake workbook now

DO NOT FILL OUT ANY MORE OF THIS INTAKE WORKBOOK!

IF THE PARTIES DO NOT HAVE AN AGREEMENT, or IF THE PARTIES WISH TO AMEND THEIR EXISTING AGREEMENT,

complete the remainder of this intake workbook.

If the parties do currently have an agreement and the remainder of this intake workbook is filled out, we will prepare an amendment to that agreement.

CUSTODY OF THE MINOR CHILDREN
Are there any court orders about custody of the kids?*
- Yes
- No
If YES, attach a copy of the Order, signed by a judge, and SKIP to the Visitation section.
PHYSICAL CUSTODY TO:
PHYSICAL CUSTODY TO:*
LEGAL CUSTODY TO:
LEGAL CUSTODY TO:*
VISITATION WITH THE MINOR CHILDREN
Are there any court orders about visitation with the kids?*
- Yes
- No
If YES, attach a copy of the Order, signed by a judge, and SKIP to the next page.
PLEASE CHOOSE A VISITATION OPTION BELOW
- REASONABLE VISITATION to the parent without primary physical custody
If you choose this option, SKIP the rest of this page
WRITE A VISITATION SCHEDULE for the non-custodial parent:

Step 1 of 10 - Page 1

INFORMATION ABOUT THE PLAINTIFF (YOU):

PLAINTIFF’S CONFIDENTIAL INFORMATION:

☞ COMPLETE THE SECTION(S) BELOW ONLY IF NEEDED

ORDERS OF PROTECTION (OOP) - PLAINTIFF

OR

CHILD ABUSE/NEGLECT PROCEEDINGS

NEW YORK STATE’S SEX OFFENDER REGISTRATION ACT

INFORMATION ABOUT THE DEFENDANT (YOUR HUSBAND/WIFE)

DEFENDANT’S CONFIDENTIAL INFORMATION:

ORDERS OF PROTECTION (OOP) - DEFENDANT

OR

CHILD ABUSE/NEGLECT PROCEEDINGS

NEW YORK STATE’S SEX OFFENDER REGISTRATION ACT

INFORMATION ABOUT THE MARRIAGE

ALIMONY

HEALTH INSURANCE FOR THE KIDS

INFORMATION ABOUT ALL CHILDREN OF THE MARRIAGE:

IMPORTANT QUESTIONS ABOUT FAMILY COURT!

PRE-EXISTING AGREEMENTS - PLEASE READ!

PRE-EXISTING AGREEMENTS

DO NOT FILL OUT ANY MORE OF THIS INTAKE WORKBOOK!

IF THE PARTIES DO NOT HAVE AN AGREEMENT, or IF THE PARTIES WISH TO AMEND THEIR EXISTING AGREEMENT,

CUSTODY OF THE MINOR CHILDREN

If YES, attach a copy of the Order, signed by a judge, and SKIP to the Visitation section.

PHYSICAL CUSTODY TO:

LEGAL CUSTODY TO:

VISITATION WITH THE MINOR CHILDREN

CHILD SUPPORT

CHOOSE ONE CHILD SUPPORT OPTION BELOW

☞ SKIP the rest of this page

OR

OR

AND Child support payments shall be made to:

OR

DAY CARE/CHILD CARE

Option:1

Option:2

Option:3

Option:4

EDUCATIONAL & EXTRAORDINARY EXPENSES

Option: 1

Option: 2

Option: 3

Option: 4

COLLEGE EXPENSES FOR THE KIDS

Option: 1

Option: 2

Option: 3

LIFE INSURANCE

Option: 1

Option: 2

Option: 3