Mediation Questionnaire

Home/Mediation Questionnaire

Swaden Resolution Services, LLC,  Mediation Questionnaire


Present Address

If you are Planning to Move, What Will Be Your New Address

Telephone Numbers at Which You Can be Reached or
at Which We Can Leave a Message For You:

What is Your Attorney's Name, Address, Phone and Fax Number


Where Were You and Your Present Spouse Married:



Children Born or Legally Adopted of the Marriage








Employment & Income


Acceptable file types: .
Maximum file size: 1mb.

Statuatory Deductions

Other PayCheck Deductions

Do You Receive Any Other Compensation From Your Employers Such As:






Other Income





Benefits
Check if You Have Any of the Following Benefits:

If Yes



If Yes

If Yes


Necessary Monthly Living Expenses
Summary of Categories







1. Housing:


2. Other Household
Total Housing

3. Medical










4. Transportation


5. Insurance

6. Recreation

7. Miscellaneous

Children

Real Estate




Included in the the Mortgage or Contract for Deed Payment?



Payments Escrowed?




Other Real Estate



Included in the mortgage or contract for deed payment?






Business Interests







Personal Property
PLEASE GIVE US YOUR ESTIMATE OF THE FAIR MARKET VALUE OF THE FOLLOWING ITEMS AND INDICATE WHO CURRENTLY HAS POSSESSION OF THE ITEMS.




Checking Accounts



Second Checking Account


Savings Account



Second Savings




Motor Vehicles



Boats, Motors, Campers, Snowmobiles, Trailers, etc. (for boats include model number)



Other: (Such as Power Equipment, Tools, Guns, Valuable Animals, etc.


Insurance
LIFE INSURANCE: (through employment or privately obtained)




If Yes Specify













Dental Insurance









Debts
LIABILITIES (include car loans and real estate mortgages - use additional space if necessary)

Outstanding bills or both husband and wife:










CREDIT CARDS (Name of card, current balance, and in whose name)