Psa Separation Agreement Worksheet

THIS FORM IS DESIGNED AND CREATED TO ASSIST YOUR ATTORNEY IN DRAFTING YOUR SEPARATION AGREEMENT. IT SHOULD NOTAND IS NOT INTENDED TO CONSTITUTE LEGAL ADVICE. ONLY YOUR ATTORNEY CAN OFFER LEGAL ADVICE CONCERNING YOUR CASE. SHOULD YOU HAVE ANY QUESTIONS ABOUT YOUR SITUATION, PLEASE CONTACT YOUR ATTORNEY IMMEDIATELY.

STIPULATION AND PROPERTY SETTLEMENT AGREEMENTINFORMATION FORM

POTENTIAL CLIENT: _________________________ CONTACT NUMBER: _________________

HUSBAND’S INFORMATIONFull Name: ___________________________________________________________________________

Address: _____________________________________________________________________________

Home Telephone: ____________________ Social Security Number: _____________________________

Date of Birth: __________________________ Place of Birth: __________________________________

Highest Level of Education: ___________ (Primary 0-12 years) ___________ (Secondary 1-8 years)

Employer: ____________________________________________________________________________

Employer’s Address: ___________________________________________________________________

Work Telephone Number: _______________________________________________________________

Is Husband in the military? ______________________________________________________________

If so, what branch: _____________________________________________________________________

What was the date of entry: ________________ What is the date of separation from military: _________

Has Husband been a resident of Virginia for the past six months? ________________________________

If no, when did he move to Virginia? ______________________________________________________

Who is responsible for providing Husband’s health insurance? __________________________________

Who is responsible for Husband’s unpaid medical expenses, including prescriptions? ________________

WIFE’S INFORMATIONFull Name (including maiden name): ______________________________________________________

Address: _____________________________________________________________________________

Home Telephone: ____________________ Social Security Number: _____________________________

Date of Birth: __________________________ Place of Birth: __________________________________

Highest Level of Education: ___________ (Primary 0-12 years) ___________ (Secondary 1-8 years)

Employer: ____________________________________________________________________________

Employer’s Address: ___________________________________________________________________

Work Telephone Number: _______________________________________________________________

Is Wife in the military? _________________________________________________________________

If so, what branch: _____________________________________________________________________

What was the date of entry: ________________ What is the date of separation from military: _________

Has Wife been a resident of Virginia for the past six months? ___________________________________

If no, when did she move to Virginia? ______________________________________________________

Who is responsible for providing Wife’s health insurance? _____________________________________

Who is responsible for Wife’s unpaid medical expenses, including prescriptions? ___________________

©Brian A. Thomasson, Esq. 2010 of 9

MARRIAGE INFORMATION

Date of marriage: _____________________________________________________________________

City and state of marriage: _____________________________________________________________

Date separated: ______________________________________________________________________

Last place you lived with your spouse: ____________________________________________________

CHILD(REN) INFORMATION

Number of child(ren) born of this marriage: _________________________________________________

Number of child(ren) adopted during the marriage: ___________________________________________

Are any child(ren) anticipated at this time? __________________________________________________

Child(ren)’s Name(s) and Social Security Number(s): Date of Birth:

_______________________________________________________ _____________________________

_______________________________________________________ _____________________________

_______________________________________________________ _____________________________

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Which parent is to have physical custody of the child(ren)? ______________________________

Visitation schedule: _____________________________________________________________

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©Brian A. Thomasson, Esq. 2010 Page 1 of 9

Is there any reason that one of you should not have legal custody?___________________________

If so, what is that reason? _________________________________________________________

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Parents may be entitled to certain tax benefits relating to the children. Is there any agreement

regarding who gets these benefits? _________________________________________________

If so, what is that agreement: ______________________________________________________

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Who provides for health insurance? ________________________________________________

Who is responsible for unpaid medical expenses, including prescriptions? _________________________

Are there any extraordinary medical expenses? _______________________________________

Do you have an agreement regarding child support and, if so, what is that agreement?

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Child support in Virginia is calculated pursuant to Virginia Code Section 20-108.2. These are

referred to as the Guidelines. If you are not following the Guidelines, you must provide a specific

reason for the deviation. In the event that you and your spouse are not following the Guidelines,

please state your reason for the deviation.

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FINANCES

It is extremely important all of your debts and assets be listed so that they can be disposed of in

the

divorce process. As such, please disclose them below fully and accurately. Be sure to note any

and

all joint debts and who is to be responsible so that those debts can be enforced in the bankruptcy.

If a debt is not listed and addressed, you may be solely responsible for that debt if your spouse

fails

to make the necessary payment(s).

Are there any bank accounts (of any sort) which need to be divided?

_________________________

If so, please state the following:

Name of Bank

___________________

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Type of Account

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Estimated Amount

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How Divided?

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Do you own or rent a home? _________________ Monthly payment? ______________

Whose name is the home in? ______________________________________________________

What is the street address of the home?

________________________________________________

What is to be done with the home? (Example, Husband will by out Wife’s interest, house will be

sold and the equity split equally, etc.)

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Do you and your spouse jointly own any motor vehicles?

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Type of Vehicle

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Any Debt

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Estimated Amount

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How Divided/Who Pays?

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Do you and your spouse have any other debt?

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Creditor

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Type of Debt

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Estimated Amount

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Is there any agreement regarding spousal support?_____________________________________

If so, what is it?______________________________________________________________

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Is there any other property (personal or real) that needs to be divided?

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What Property

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What has been omitted that need to be addressed?


VS4 - REPORT OF DIVORCE OR ANNULMENT

With any final divorce decree, a VS4 form must be filed. This is reported to the Department of

Health so that it can track divorces as well as marriages. Please answer these questions below so

that we can submit a VS4.

HUSBAND

Full Name: ____________________________________________________________________

Social Security Number: _________________________________________________________

Race: ________________________________________________________________________

Place of Birth: _______________________________________________ (State or Foreign Country)

Date of Birth: __________________________________________________________________

Number of This Marriage: ___________________________________________(First, Second, etc.)

Education: ___________________________________________________ (Highest level completed)

Usual Residence: _______________________________________________________________

WIFE

Full Name (include maiden name): _________________________________________________

Social Security Number: _________________________________________________________

Race: ________________________________________________________________________

Place of Birth: _______________________________________________ (State or Foreign Country)

Date of Birth: __________________________________________________________________

Number of This Marriage: ___________________________________________(First, Second, etc.)

Education: ___________________________________________________ (Highest level completed)

Usual Residence: _______________________________________________________________

MARRIAGE/DIVORCE

Place of Marriage: ____________________________________________ (State or Foreign Country)

Date of Marriage: _______________________________________________________________

Number of children under the age of 18 in this family: __________________________________

Number of children under 18 in this family whose physical custody was awarded to:

_______________ Husband _______________ Wife

_______________ Joint _______________ Other No children


Date of Separation: _____________________________________________________________


Psa Separation Agreement Worksheet

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