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Levitt & Quinn Intake Sign Up

FAMILY LAW INTAKE

Full Name : Date of Birth : Other Names : Preferred Language : Your Gender : Your Address : City : Your Zip Code : Phone : Leave a message : Yes No
Email : Your Ethnicity / Race :
Asian Latino Pacific Islander Black
Native American White Other
Total # in Household : # Adults in Household : # Minors in Household : Currently Employed : Yes No

Monthly CalWorks/TANF : Monthly CAPI : Monthly Child Support : Monthly Disability(+SDI) : Monthly Wages : Monthly GR/GROW : Monthly Pension: Monthly Social Security : Monthly Spousal Support : Monthly SSI/SSDI : Monthly Trusts/Dividends / Stocks :
Monthly Unemployment : Monthly Veteran Benefits : Monthly Worker's Comp : Monthly Other : Total Monthly Income : Support For Yourself : Current Housing: Rent Temporarily with Family/Friends Shelter Assisted Living
Sec 8/Subsidized Housing Mobile Home Own Home Other How Did You Hear About Levitt Quinn: Friend Court Referring Organization
Internet Search Returning Other
Current Spouse's Name : Spouse's Date of Birth : Spouse's Other Names : Type of Case You Need Help With : How Will You Pay $40 Intake Fee? : Money Order Credit/Debit Card Other
Has Court Case Been Filed? : Yes No

CASE INFORMATION (IF FILED)

Next Court Date : Case Number : Courthouse Location : Opposing Party Full Name : Opposing Party Date of Birth : Opposing Party Other Names : Opposing Party Address : Opposing Party City : Opposing Party Zip Code : Phone : Opposing Party's Spouse Name : Opposing Party Spouse's Date of Birth :

GENERAL QUESTIONS

Has a Lawyer ever helped you in a family law matter? : Yes No If Yes, Attorney Name : Are you/spouse business owners or self employed? : Yes No If Yes, Type of Business :
Do you/spouse own property in another state ? : Yes No If Yes, Location of Property: Do you/spouse own property in foreign country ?: Yes No If Yes, Location of Property : Are you/family member a member of armed forces? : Yes No If Yes, Who? : Are you/family member a U.S. Veteran? : Yes No If Yes, Who? : Do you/household member have a disability? : Yes No If Yes, Who? : Would you like to resolve case through mediation? : Yes No If Yes, Attend Free Class? : Do you identify as :
Straight Lesbian Gay Bisexual Other Decline

Household Member 1 (Including Children, Except Yourself) Name: DOB: Relationship: Monthly Income: % Time in Household:

Household Member 2 (Including Children, Except Yourself) Name: DOB: Relationship: Monthly Income: % Time in Household:

Household Member 3 (Including Children, Except Yourself) Name: DOB: Relationship: Monthly Income: % Time in Household:

Minor Child Not in Household 1 Name: DOB: City / State: Time in Current Location:

Minor Child Not in Household 2 Name: DOB: City / State: Time in Current Location:

Minor Child Not in Household 3 Name: DOB: City / State: Time in Current Location: