JEFFREY T. ORNDORFF CO., L.P.A.
117 SOUTH STREET, SUITE 110
P.O. BOX 263
CHARDON, OHIO 44024
TELEPHONE: (440) 285-1710   FAX: (440) 285-1723

DOMESTIC RELATIONS CLIENT INFORMATION SHEET

I.   PERSONAL INFORMATION

A.	CLIENT - PERSONAL

Name: ___________________________________________________________

Maiden Name/Alias: ______________________________________________

D.O.B: _______________________	S.S.N.: ______________________

Current Residence Address: ______________________________________

_________________________________________________________________

Length of Residence: County _______________ State _______________

Telephone: Home ___________ Cell ___________ Work _______________

Number of Previous Marriages: ___________________________________

Member of U.S. Armed Forces: Yes ______		No _______

If yes, give branch and date of service: ________________________

_________________________________________________________________

Education: ______________________________________________________

B.	CLIENT - EMPLOYMENT

Current Employer: _______________________________________________

Business Address: _______________________________________________
	
			   _______________________________________________

Title or Position: ______________________________________________
Salary Wage: _______________		Pay Period: __________________

Job Description: ________________________________________________

_________________________________________________________________

C.	SPOUSE - PERSONAL

Name: ___________________________________________________________

Maiden Name/Alias: ______________________________________________

D.O.B: _______________________	S.S.N.: ______________________

Current Residence Address: ______________________________________

_________________________________________________________________

Length of Residence: County _______________ State _______________

Telephone: Home ___________ Cell ___________ Work _______________

Number of Previous Marriages: ___________________________________

Member of U.S. Armed Forces: Yes ______		No _______

If yes, give branch and date of service: ________________________

________________________________________________________________

Education: ______________________________________________________

D.	SPOUSE - EMPLOYMENT

Current Employer: _______________________________________________

Business Address: _______________________________________________
	
			   _______________________________________________

Title or Position: ______________________________________________

Salary Wage: _______________		Pay Period: __________________

Job Description: ________________________________________________

_________________________________________________________________

E.	MARRIAGE

Date of Marriage: ________________ Place: _______________________

Date of Separation: ______________

Is Wife Now Pregnant: Yes _______   No ______

Previous Marital Problems: ______________________________________

_________________________________________________________________

_________________________________________________________________

F.	MARITAL AGREEMENTS

Prenuptial Agreement: Yes ______		No ______

Other Written Agreements: Yes ______	No ______

G.	CHILDREN OR OTHER DEPENDENTS

Name: ________________________ Age: _______	    D.O.B.: ________

	 ________________________ Age: _______	    D.O.B.: ________

	 ________________________ Age: _______	    D.O.B.: ________

	 ________________________ Age: _______	    D.O.B.: ________

State the places and dates the child(ren) has/have lived during the past five (5) yeas and the name and current address of the person with whom the child(ren) lived during that period:
________________________________	______________________________

_________________________________	______________________________

_________________________________	______________________________

_________________________________	______________________________
_________________________________	______________________________

Any unusual health problems?   Yes ______	No ______

If yes, describe: _______________________________________________

_________________________________________________________________

II.   ASSETS

A.	REAL ESTATE

Home Description: _______________________________________________

_________________________________________________________________

Legal Title:                      Date of Purchase:              

Purchase Price: ____________ Down Payment: $___________

Source: _________________________________________________________

Current Market Value: $__________	

Basis of Opinion: _______________________________________________

Cost of Improvements: $_____________ Type: ______________________

First Mortgage Holder: __________________________________________

Original Mortgage Amount: $__________	Current Balance: $_______

Monthly Payment: $__________			Taxes: $_________________

Second Mortgage Holder:                                          

Original Mortgage Amount: $             Current Balance: $       

Balance: $                  	Monthly Payment: $                 

Use of Loan Proceeds:                                            

Other Liens:                                                     

Individual Contributions Toward Purchase & Maintenance:          

                                                                 

B.	OTHER REAL ESTATE

Home Description:                                                

Legal Title:                      Date of Purchase:              

Purchase Price: ____________ Down Payment: $___________

Source: _________________________________________________________

Current Market Value: $__________	

Basis of Opinion: _______________________________________________

Cost of Improvements: $_____________ Type: ______________________

First Mortgage Holder: __________________________________________

Original Mortgage Amount: $__________	Current Balance: $_______

Use of Loan Proceeds:                                            

Other Liens:                                                     

Individual Contributions Toward Purchase & Maintenance:          

                                                                 

C.	HOUSEHOLD GOODS

Number of Rooms of Furniture:                                    

Approximate Age:              	Approximate Value:            

Particular Items:                                                

                                                                  

D.	AUTOMOBILES

Make/Model:             Year:           Date of Purchase:        

Purchase Price: $               	Current Value: $              

Condition:                                                        

Mortgage Balance: $               Titled:                        

Holder:                                                          

Notes:                                                           

Make/Model:             Year:           Date of Purchase:        

Purchase Price: $               	Current Value: $              

Condition:                                                        

Mortgage Balance: $               Titled:                        

Holder:                                                          

Notes:                                                           

E.	LIFE INSURANCE POLICIES

Life Insurance Company:                                          

Face Amount: $                		Type:                    

Insured:                             Owner:                      

Beneficiary(ies):                                                

Monthly Payments: $            Present Cash Value: $              

Life Insurance Company:                                          

Face Amount: $                		Type:                    

Insured:                             Owner:                      

Beneficiary(ies):                                                

Monthly Payments: $            Present Cash Value: $              

Life Insurance Company:                                          

Face Amount: $                		Type:                    

Insured:                             Owner:                      

Beneficiary(ies):                                                

Monthly Payments: $            Present Cash Value: $              

F.	MEDICAL & HOSPITALIZATION INSURANCE

Company:                                                         

Monthly Premium: $           		Paid By:                      

Insured/Covered Dependents:                                      

G.	BUSINESS INTERESTS (Closely held Corporate Interest, Joint Ventures, Partnership, Sole Proprietorships)

Name:                                                            

Type of Business:                                                

Percentage of Ownership:                                         

Original Amount of Investment:                                   

Date Acquired:                        Value: $                    

H.	BANK ACCOUNTS

Bank:                                      Type:                 

Acct. No.:                     Balance as of                      

Balance: $                   

Record Owner:                          Source:                   

Notes:                                                           

Bank:                                      Type:                 

Acct. No.:                     Balance as of                      

Balance: $                   

Record Owner:                          Source:                   

Notes:                                                           

Bank:                                      Type:                 

Acct. No.:                     Balance as of                      

Balance: $                   
Record Owner:                          Source:                   

Notes:                                                           

Bank:                                      Type:                 

Acct. No.:                     Balance as of                      

Balance: $                   

Record Owner:                          Source:                   

Notes:                                                           

I.	MONEY MARKET OR MUTUAL FUNDS

Financial Institution:                                           

Type:                                                             

Acct. No.:                  Balance or Value: $                  

Record Owner:                                                    

Source:                                                          

Notes:                                                            

Financial Institution:                                           

Type:                                                             

Acct. No.:                  Balance or Value: $                  

Record Owner:                                                    

Source:                                                          

Notes:                                                            

J.	STOCKS

Company:                                                          

No. of Shares:                                                   

Record Owner:                                                    

Current Value:                                                   

Company:                                                          

No. of Shares:                                                   

Record Owner:                                                    

Current Value:                                                   

Company:                                                          

No. of Shares:                                                   

Record Owner:                                                    

Current Value:                                                   

Company:                                                          

No. of Shares:                                                   

Record Owner:                                                    

Current Value:                                                   

K.	BONDS

Issuer:                                  Type:                   

Record Owner:                            Face Value:             

L.	RETIREMENT PLANS & IRA’S

1.	Date(s) of Contribution(s):                                 
	
	Amount(s) of Contribution(s):                               

	Present Value: $                                            

	Account Held With:                                          

2.	Date(s) of Contribution(s):                                 
	
	Amount(s) of Contribution(s):                               

	Present Value: $                                            

	Account Held With:                                          

3.	Date(s) of Contribution(s):                                 
	
	Amount(s) of Contribution(s):                               

	Present Value: $                                            

	Account Held With:                                          

4.	Date(s) of Contribution(s):                                 
	
	Amount(s) of Contribution(s):                               

	Present Value: $                                            

	Account Held With:                                          

M.	EMPLOYMENT BENEFITS (Pension, Stock Option, Deferred
	Compensation & Profit Sharing Plan)

Name of Plan:                                                    

Company:                                                         

In Whose Name:                                                   

Value $                                                          

Amount Invested: $                                               

Employee Contribution: $                                         

Name of Plan:                                                    

Company:                                                         

In Whose Name:                                                   

Value $                                                          

Amount Invested: $                                               

Employee Contribution: $                                         

Name of Plan:                                                    

Company:                                                         

In Whose Name:                                                   

Value $                                                          

Amount Invested: $                                               

Employee Contribution: $                                         

N.	OTHER ASSETS

	Description			Date Acquired			Value

1.	                                                            

2.	                                                            

3.	                                                            

4.	                                                            

5.	                                                            

O.	OTHER SOURCES OF INCOME

	1.                                        H         W       

	2.                                        H         W       

	3.                                        H         W       

P.	DEBTS

			   Balance     Monthly
	Creditor		Due		Payment		Source   H   W   J

1.                                                               

2.                                                               

3.                                                               

4.                                                                

5.                                                               

6.                                                                

Q.	PROPERTY BROUGHT TO THE MARRIAGE

											H    W

1.	Description:                                                

	Date Acquired: Self                	Spouse:             

	Cost: Self                         	Spouse:             

	Value at Time of Marriage:   Self          	Spouse         

	Present Value: Self              		Spouse              

2.	Description:                                                

	Date Acquired: Self                	Spouse:             

	Cost: Self                         	Spouse:             

	Value at Time of Marriage:   Self          	Spouse         

	Present Value: Self              		Spouse              

3.	Description:                                                

	Date Acquired: Self                	Spouse:             

	Cost: Self                         	Spouse:             

	Value at Time of Marriage:   Self          	Spouse         

	Present Value: Self              		Spouse              

4.	Description:                                                

	Date Acquired: Self                	Spouse:             

	Cost: Self                         	Spouse:             

	Value at Time of Marriage:   Self          	Spouse         

	Present Value: Self              		Spouse              

5.	Description:                                                

	Date Acquired: Self                	Spouse:             

	Cost: Self                         	Spouse:             

	Value at Time of Marriage:   Self          	Spouse         

	Present Value: Self              		Spouse              

R.	GIFTS DURING MARRIAGE

											H    W

1.	What: Self                                                  

		 Spouse                                                

	From Whom: Self                                             

		 	 Spouse                                           

	To Whom: Self                                               

		    Spouse                                             

	Present Value: Self                                         

			     Spouse                                       

2.	What: Self                                                  

		 Spouse                                                

	From Whom: Self                                             

		 	 Spouse                                           

	To Whom: Self                                               

		    Spouse                                             

	Present Value: Self                                         

			     Spouse                                       

3.	What: Self                                                  

		 Spouse                                                

	From Whom: Self                                             

		 	 Spouse                                           

	To Whom: Self                                               

		    Spouse                                             

	Present Value: Self                                         

			     Spouse                                       

4.	What: Self                                                  

		 Spouse                                                

	From Whom: Self                                             

		 	 Spouse                                           

	To Whom: Self                                               

		    Spouse                                             

	Present Value: Self                                         

			     Spouse                                       

S.	INHERITANCES DURING MARRIAGE

											H    W

1.	Amount or Item: Self                                        

				 Spouse                                      

	Present Value:  Self                                        

				 Spouse                                      

T.	NAME & ADDRESS OF YOUR ACCOUNTANT (If any)

                                                                 

U.	NAME & ADDRESS OF YOUR FINANCIAL ADVISOR (If any)

                                                                 

V.	MISCELLANEOUS NOTES:

                                                                 

                                                                  

                                                                 

						                                   
						Client’s Signature
						Date: