Separation Agreement Intake | Balbach & Davenport Legal

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BALBACH & DAVENPORT LEGAL

Virtual Family Law | North Carolina

Separation Agreement — Client Intake Form

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Before you start: This form is confidential and protected by attorney-client privilege. There are no wrong answers — just give us the full picture so we can draft an agreement that actually protects you. Write “N/A” wherever something doesn’t apply.

Section 1 — The Parties

Party 1 (You)

Full Legal Name

Date of Birth

SSN (last 4 only)

Current Address

County

Phone

Best Contact Method

Employer / Occupation

Gross Monthly Income

Party 2 (Your Spouse)

Full Legal Name

Date of Birth

SSN (last 4 only)

Current Address

County

Phone

Employer / Occupation

Gross Monthly Income

Marriage Information

Date of Marriage

Place of Marriage (City, State)

Date of Separation

Divorce filing? Case # / County

Spouse's attorney (if represented)

Prior marriages by either party?

Yes — describe: No

Any DVPO or pending litigation?

Yes — describe: No

Section 2 — Minor Children

Do you have minor children together?

Yes No — skip to Section 3

Child's Full Name	Date of Birth	Currently Lives With	School / Special Needs

Custody & Parenting Time

Proposed Legal Custody

Joint Sole — Party 1 Sole — Party 2 TBD

Proposed Physical Custody

Joint / Shared Primary — Party 1 Primary — Party 2 TBD

Proposed Parenting Schedule

Holiday / School Break Arrangements

Child Support

Proposed Monthly Support Amount

Who carries health insurance for children?

Party 1 Party 2 Discuss

Uncovered medical/dental/vision split

Childcare & extracurricular split

Tax dependency claim(s)

Special considerations (therapists, IEPs, relocation concerns, travel restrictions)

Section 3 — Real Property

Do you own real property together or separately?

Yes No — skip to Section 4

Property Address	Deed — Whose Name(s)	Approx. Value	Mortgage Balance	Proposed Disposition

Disposition: Party 1 keeps | Party 2 keeps | Sell & split proceeds | Buy out | TBD

If one party keeps the home, how/when will the other be removed from the mortgage?

Any property acquired before marriage or by gift/inheritance? (May affect classification)

Section 4 — Vehicles

Year / Make / Model	Title In Whose Name	Approx. Value	Loan Balance	Who Keeps It

Section 5 — Financial Accounts & Investments

Account Type	Institution	Whose Name(s)	Approx. Balance	Proposed Division

Division: Party 1 keeps | Party 2 keeps | Split equally | Other

Retirement Accounts

Note: Dividing retirement accounts may require a QDRO — we'll flag this for you.

Type (401k, IRA, Pension, etc.)	Account Holder	Institution	Approx. Balance	Proposed Division

Section 6 — Debts & Liabilities

Type	Creditor	In Whose Name(s)	Balance	Who Pays Going Forward

Any joint or separate tax debt? Describe

Any pending lawsuits or judgments? Describe

Section 7 — Personal Property & Household Items

Focus on items of significant value or sentimental importance where there may be disagreement.

Items Party 1 is keeping

Items Party 2 is keeping

Items in dispute or undecided

Pets — who keeps them? Any shared arrangement?

Business interests, professional licenses, or intellectual property to address

Section 8 — Spousal Support (Alimony)

Is spousal support being proposed?

Yes — Party 1 pays Party 2 Yes — Party 2 pays Party 1 No — waiving alimony TBD

Proposed Monthly Amount

Duration (months/years, or until event)

Termination Events (remarriage, cohabitation, etc.)

Relevant factors (income disparity, health, career sacrifices, length of marriage)

Section 9 — Insurance & Benefits

Health insurance — who is covered under whose plan currently?

Post-separation health coverage plan

Life insurance policies to address (beneficiary changes needed?)

HSA, FSA, or other benefit accounts to address

Section 10 — Additional Provisions

Name change requested by either party?

Yes — who: No

How would you describe the process — collaborative, or significant conflict on key issues?

Anything else we should know going into this?

Authorization & Acknowledgment

By signing below, you confirm that the information provided is accurate to the best of your knowledge and authorize Balbach & Davenport Legal to use it in preparing your separation agreement. You understand this form is protected by attorney-client privilege.

Client Signature

Printed Name

Date