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45 Jason Street , Arlington, Massachusetts 02476
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Massachusetts Mediation Services

From the Law Office of Robert P. Murray

Robert P. Murray, Esquire

Divorce Mediation Homework

If you are interested in mediation through this office, it will save time and money if you and your spouse complete the following questionnaire prior to our first mediation session.

Your answers to these questions should be written on this sheet and brought with you to the session. Use more paper if you need more space. Please keep a copy for yourself.

    1. Identifying Data:
      1. Full Name:
      2. Maiden Name (if applicable):
      3. Address:
      4. Home Telephone Number:
      5. Work Address:
      6. Work Telephone Number:
      7. Preferred Mailing Address (if different from above):
      8. Date of Birth:
      9. Social Security Number:
    2. Marriage:
      1. Full Name of Spouse:
      2. Spouse’s Date of Birth:
      3. Date and Place of Marriage:
      4. If separated, date and place you last lived together:
      5. Have there been prior separations? If so, list dates and duration:
    3. Efforts at Reconciliation:
      1. Have there been efforts at reconciliation of this marriage?
      2. If so, please describe: how long ago? Are these efforts still continuing?
      3. Who provided professional help, if anyone?
    4. Legal Representation:
      1. Do you have an attorney in this matter?
      2. Name:
      3. Address:
      4. Telephone Number:
    5. Children of this Marriage:
        1. Living with whom:
        2. Is any third person involved in their care?
        3. Present arrangements for sharing time with the children, if separated:
        4. List any current medical problems of the children or any anticipated medical or dental expenses.
        5. Are any of the children receiving psychological counseling?

      Do any of them have special educational needs?
      Are any of them having problems in school?

        1. List any trust funds or other property owned by the children or held for them.

      Do you expect them to receive property in the future, by gift or inheritance?

Please provide the names, dates of birth and school grade for each of your children:

    1. Prior Marriages, if any:
      1. Date:
      2. Place:
      3. Prior Spouse’s Name:
      4. Where/When/How Ended:
      5. Children of Prior Marriage; if any: (again, please provide the names, dates of birth and school grade for each child) Also, indicate who each child is living with.
      6. Are there any existing financial or custody obligations?
    2. Employment and Vocational Skills:
      1. Employer:
      2. Can you be called at work?
      3. Work hours:
      4. Salary (annual) or hourly wage:
      5. Bonus, if any:
      6. Other Compensation or Benefits (including fringe benefits):
      7. Brief Job Description or Title:
      8. Length of Employment:
      9. Retirement Plans (attach all current data you can obtain): YES NO
      10. Post-secondary Education, including degrees received and years of attendance:
      11. Special Skills:
      12. List any other work or jobs you have:
    3. Medical Insurance:
      1. Type of medical insurance and name of insurer:
      2. Who pays the premium? What is the cost?
      3. Who is covered by this policy?
      4. List any medical problems you have:
      5. Are you receiving psychological counseling?
      6. How much psychological care is paid by insurance?
    4. Disability Insurance:
      1. Insurer:
      2. Amount:
      3. Who pays the premium?
    5. Life Insurance on Any Family Member:
      1. Company:
      2. Face value:
      3. Cash Value:
      4. Loans against Policy:
      5. Beneficiary:
      6. Owner:
      7. Who pays the premium?
      8. Ordinary or whole life, term, annuity or other type?
      9. Insured:
    6. Legacies or Inheritances:
      1. Received prior to Marriage:
      2. Received during Marriage:
      3. Anticipated:
    7. Financial Situation:

Please fill in a Financial Statement.

Each party should print out the form and fill it in as best as you can. This will not be a final version, but serves to give a basic financial picture, much of which is required as part of the divorce procedure.

    1. Tax Returns:

Please bring in a copy of your federal and state tax returns for the past three years, whether filed jointly or separately.

    1. Proposals:

Describe any agreements the two of you have reached in terms of your divorce. List also any proposals either of you has suggested, or you would like to offer now for consideration, in order to resolve remaining issues.

    1. Other Information:

Please list any other information that you believe may be germane to the mediation process or the terms of a divorce agreement.

If you have any questions about divorce mediation, contact the Law Office of Robert P. Murray, Esq. today.