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Willis & Willis & Co. LPA
A Legal Professional Association
DOMESTIC INTAKE SHEET
Today's Date:
First Name:
Nickname:
Middle Name:
Last Name:
Maiden Name:
Social Security Number:
Date of Birth:
(mm/dd/yyyy)
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zipcode:
County:
Email:
Home Phone:
Work Phone:
Cell Phone:
Date of Marriage:
Place of Marriage: City:
County/State:
Marital Address:
How Long There?
Children
Are there any children born of this marriage, or between you and your spouse prior to the marriage?
Yes
No
Are there any children born prior to the marriage?
Yes
No
Are there any step-children?
Yes
No
If yes to any of the above, please list the following:
Child's Full Name:
Date of Birth:
SSN:
Child's Full Name:
Date of Birth:
SSN:
Child's Full Name:
Date of Birth:
SSN:
Child's Full Name:
Date of Birth:
SSN:
Child's Full Name:
Date of Birth:
SSN:
Child's Full Name:
Date of Birth:
SSN:
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