SAM HASLER

A TTORNEY AT L AW
1106 Meridian Plaza, Suite 251 Anderson, IN 46016

Telephone: 765-641-7906 Fax: (765)-374-3811

Web Page: http://samhasler.justia.net/index.html Web Log: http://haslerlaw2.blogspot.com/

E-mail: samuelhasler@yahoo.com

CLIENT CUSTODY CONSULTATION INFORMATION

Thank you for choosing Hasler Law Office to handle your legal matter. In order to assist you better, please
take a few moments to answer the following questions. The first section concerns general questions, and the second
more specific matters. While lengthy, the idea here is use your time more for answering your questions than in
gathering the information contained in this questionnaire.

1. Please list your full name: ____________________________________________________

2. Current address where you are residing, including the Zip Code:

____________________________________________________

____________________________________________________

3. Do you have another address to which you would like to have any mail sent from this office?

Yes _______ No ________

If yes, please give the complete mailing address as it should appear on the mailing envelope, including the
Zip Code:

____________________________________________________

____________________________________________________

4. Please list any and all telephone numbers where you can be reached, including pager numbers and area
codes:

____________________________________________________

____________________________________________________

CUSTODY QUESTIONNAIRE PROVIDED BY SAM HASLER

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5. If we are unable to reach you using the telephone numbers provided herein, is there anyone else we can
contact to get in touch with you? Yes _______ No ________

If yes, please list their names, full address and telephone numbers, including pager numbers and area codes:
_____________________________________________________

____________________________________________________

____________________________________________________

6. Are you employed? Yes_____ No______

If yes, please state where and the job title and how long you have been there:

____________________________________________________

____________________________________________________

____________________________________________________

7. Have you been involved in litigation before? If yes, please state when and what type of lawsuit? What was
the outcome? Were you pleased with the legal system?

____________________________________________________

____________________________________________________

8, How did you choose Hasler Law Office for your consultation/representation?

____________________________________________________

____________________________________________________

9. How will you be paying for your consultation today? ________________________________

10. Would it make any difference to you if you were allowed to pay by credit card? Yes ____ No ______

CUSTODY QUESTIONNAIRE PROVIDED BY SAM HASLER

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These questions deal more specifically with the issues of your matter. Not all questions will apply, so do not
worry if you do not have an answer.

I. What is name of the other parent? ___________________________

A. The other parent’s age? ___________________________

B. The other parent’s Social Security number? ___________________________

II. How many children? Yes _____ No ______

A. If “Yes”, then are any of the children younger than 21? Yes _____ No ______

B. If younger than 21, where do they live? ______________________________

C. Is the wife now pregnant? Yes _____ No ______

D. Names, Date of Birth, age, current addresses, and social security numbers for the children under 21
years of age.

Child’s name Date of Birth Age Current Addresses social security

number

E. Give me any facts why it is in the child(ren)’s best interests for you to have custody.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

CUSTODY QUESTIONNAIRE PROVIDED BY SAM HASLER

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 F. Give me any facts why it is in the child(ren)’s best interests for you to have custody.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

III. Since child support will be at issue too, I need the following income information:

A. What is your weekly gross income? _______________________

(1) If you are not working, please explain why not?

___________________________________________________________________________________

___________________________________________________________________________________

C. Do you pay child support? Yes _____ No ______

(1) If so, how much a week?

______________________

D. Do you have custody of children from a prior marriage? Yes _____ No ______

E. What is the other parent’s weekly gross income? ______________________

F. Does other parent pay child support? Yes _____No ______

(1) If so, how much a week?

______________________

G. Does other parent have custody of children? Yes _____ No ______

H. Are there child care expenses so that you can work? Yes _____No ______

(1) How much in work related child care expenses? Yes _____ No ______

(2) Who pays this? _____________________

CUSTODY QUESTIONNAIRE PROVIDED BY SAM HASLER

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IV. Since parenting time will be at issue, please tell me what visitation you would like to have and what visitation
you would like to see for the other parent.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Date: _____________________

_________________________________________________
Your name

CUSTODY QUESTIONNAIRE PROVIDED BY SAM HASLER

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