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Client reference:

Personal Details – party 1

Name:
Date of birth: Age:
Address:
Email:
Phone:
Do you have any special medical needs:
Have you been subject to any emotional or physical abuse or been accused of being abusive during the relationship?:
Have the police been involved?
Please provide details (if applicable):
Would you consider discussing the issues arising out of the breakdown in your relationship with a mediator?
Current employment: Employed full time
Have you formed another relationship?:

Personal details – party 2

Name:
Date of birth: Age:
Address:
Phone:
Email:
Does the other party have any special medical needs?:
Would the other party consider discussing the issues arising out of the breakdown in your relationship with a mediator?:
Current employment: Employed full time
Has the other person formed another relationship?:

Relationship & Mediation

Date cohabitation began:
Date of marriage:
Date of separation:
Case number:
Date of petition:
Date of decree nisi/conditional order:
Date of decree absolute/final order:
Have either you or the other party attended any form of mediation?:
What was the outcome?:

Children

Name:
Date of birth:
What is party 1’s relationship to this child?:
What is party 2’s relationship to this child?:
Does this child have any special medical needs?:
Details:
Where does this child live?:
Which stage of education has the child reached?:
Are private school fees/university fees being paid?:
Please give details:
If there is anything else you feel is significant about this child that I should be aware of, please state it here:

The Family Home

Address of the last home you lived in together. This is/was your main home.: 7 St Aldwyns Road
Manchester, Greater Manchester M20 3JF
United Kingdom
Has this property been sold or the tenancy terminated?: Neither of the above.
Is this property owned or rented?: Owned just in party 2’s name
Is there a mortgage on the property?: Yes
What type of mortgage is it?: Part interest only part repayment
Name of mortgage lender: Barclays
Address of the mortgage lender: Barclays Bank
London, NW1 2BN
United Kingdom
Amount outstanding on the mortgage: £360,000
Is the value of the property agreed?: Yes
Agreed valuation: £1,000,000
Estimated estate agency fees: £10,000
How has the valuation been arrived at?: Rightmove
If there are any other details that you think I should be aware of please state them here:

Other Real Property

Bank Accounts

Nickname for account:
Whose account is it?:
Name of Bank:
Type of account:
Balance today:
Please state any other details you feel may be relevant here:

Investments

Whose investment is this?:
Type of investment:
Number of shares etc:
Price per share:
Current value today:
Please state any other details you feel may be relevant:

Insurance Policies

Nickname:
Policy Holder:
Policy Holder:
Name of life assured:
Name of life assured:
Does this policy have a surrender value?
Maturity date:
Surrender value today:
Is this a whole of life policy only that only pays out on the death of the assured person?:
Sum payable on death of the life assured:
Sum payable in respect of critical illness:
Name of person to whom the benefits are assigned:
Monthly premium:
Please state any other details that may be relevant:

Cash

Please provide details of any cash not in a bank account that either party holds:
Cash is held by:
Amount:

Money Owed to Either Party

Please provide details of any money owed to either party:
Amount owed:£

Personal Belongings Worth Over £500

What is the item?:
Who owns this item?:
Is the value agreed?:

Please give any other details that you believe may be relevant:

Business Assets

Name of the business:
What type of business is this?:
Who owns/has a share in this business?:

Please set out any other details you believe may be relevant:

Other Assets

Name of the asset
What type of asset is this?
Who owns/has a share in this asset?

Please give any details you believe may be relevant:

Liabilities

Type of liability:
Whose liability is this?:

Income

Case reference: