Encrypted Input Form

Secure Web Information Form Transfer
(SWIFT)

Directions:

  1) This is a single session data entry form. Complete and review all your entries before clicking "Submit Now."
  2) After reviewing your entries, click the "Submit Now" button at the bottom of the form to send your data.
  3) Contact and inform your attorney that you submitted the requested information.

IDENTIFICATION
1. Your Email (required)
2. Attorney Email (required)

3. Extra Password
Either leave blank, or give this password to your attorney. In either case, your information is always encrypted for privacy. Complete this password field if you plan on entering sensitive information.
Automatic Encryption: (High Security)

MAIN MENU
Enter Confidential-Master Information Form
Enter Monthly Household Budget Data
Enter PropertyCalc Data

Confidential-Master Information Form

To Return to Main Menu, Click Here
SINGLE SESSION -- ENTER ALL DATA ON ALL FORMS AT ONE TIME
After entering ALL data, you must click the "Submit Now" button
on the bottom of this form to send your data!

GENERAL INFORMATION	*Press Tab Key to Move From Field to Field
4. County Name
5. Date of Marriage
6. Where Married
7. Date of Physical Separation
8. Marital Residence Occupied By
9. Number of Children Ever Born Alive of This Marriage
10. Number of Minor Children

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Party 1 - INFORMATION (The Client of the Attorney whose email is listed above) (See Line 2)	*Press Tab Key to Move From Field to Field
NAME
11. Party 1 's Title (i.e., Mr., Dr..)
12. Party 1 's First Name
13. Party 1 's Middle Name
14. Party 1 's Last Name
TELEPHONE
15. Party 1 's Day Phone
16. Party 1 's Evening Phone
17. Party 1 's Msg./Pager Phone
18. Party 1 's Fax Phone
RESIDENTIAL ADDRESS
19. Party 1 's Address
20. Party 1 's City
21. Party 1 's State
22. Party 1 's Zip
MAILING ADDRESS
Leave blank if you wish to use your residential address as your mailing address.
23. Party 1 's Mailing Address
24. Party 1 's Mailing City
25. Party 1 's Mailing State
26. Party 1 's Mailing Zip
EMPLOYMENT
27. Party 1 's Employer Name
28. Party 1 's Employer Phone
29. Party 1 's Employer Address
30. Party 1 's Employer City
31. Party 1 's Employer State
32. Party 1 's Employer Zip
VITAL STATISTICS/CONFIDENTIAL IDENTIFICATION INFORMATION
	You may wish to password protect this form if you complete this field.
33. Party 1 's Soc. Sec. Number
34. Party 1 's Birth date:
35. Party 1 's Birthplace:
36. Party 1 's Maiden Name:
37. Party 1 's Highest Education Achieved:
38. Party 1 's Number of This Marriage:
39. If Previously Married, Number Ended in Death:
40. Number Divorced or Annulled:
HEALTH INSURANCE INFORMATION
GROUP HEALTH PLAN #1
41. Group Health Plan:
42. Address Line 1:
43. Address Line 2:
44. Address Line 3:
45. Address Line 4:
46. Identification Number:
47. Plan Administrator:
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GROUP HEALTH PLAN #2
48. Group Health Plan:
49. Address Line 1:
50. Address Line 2:
51. Address Line 3:
52. Address Line 4:
53. Identification Number:
54. Plan Administrator:
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Party 2 INFORMATION (The Other Party)	*Press Tab Key to Move From Field to Field
NAME
55. Party 2 's Title (i.e., Ms. Mrs., Dr.)
56. Party 2 's First Name
57. Party 2 's Middle Name
58. Party 2 's Last Name
TELEPHONE
59. Party 2 's Day Phone
60. Party 2 's Evening Phone
61. Party 2 's Msg./Pager Phone
62. Party 2 's Fax Phone
RESIDENTIAL ADDRESS
63. Party 2 's Address
64. Party 2 's City
65. Party 2 's State
66. Party 2 's Zip code
MAILING ADDRESS
Leave blank if you wish to use your residential address as your mailing address.
67. Party 2 's Mailing Address
68. Party 2 's Mailing City
69. Party 2 's Mailing State
70. Party 2 's Mailing Zip
EMPLOYMENT
71. Party 2 's Employer Name
72. Party 2 's Employer Phone
73. Party 2 's Employer Address
74. Party 2 's Employer City
75. Party 2 's Employer State
76. Party 2 's Employer Zip
VITAL STATISTICS/CONFIDENTIAL IDENTIFICATION INFORMATION
	You may wish to password protect this form if you complete this field.
77. Party 2 's Soc. Sec. Number
78. Party 2 's Birth date:
79. Party 2 's Birthplace:
80. Party 2 's Maiden Name:
81. Party 2 's Highest Education Achieved:
82. Party 2 's Number of This Marriage:
83. If Previously Married, Number Ended in Death:
84. Number Divorced or Annulled:
HEALTH INSURANCE INFORMATION
GROUP HEALTH PLAN #1
85. Group Health Plan:
86. Address ln 1:
87. Address ln 2:
88. Address ln 3:
89. Address ln 4:
90. Identification Number:
91. Plan Administrator:
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GROUP HEALTH PLAN #2
92. Group Health Plan:
93. Address Line 1:
94. Address Line 2:
95. Address Line 3:
96. Address Line 4:
97. Identification Number:
98. Plan Administrator:
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CHILDREN INFORMATION
OLDEST CHILD
99. Oldest Child's First and Middle Name:
100. Oldest Child's Last Name:
101. Oldest Child's Age:
102. Oldest Child's Birth date
	You may wish to password protect this form if you complete this field.
103. Oldest Child's SSN
104. Oldest Child Resides with
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2ND CHILD
105. Second Child's First and Middle Name:
106. Second Child's Last Name:
107. Second Child's Age:
108. Second Child's Birth date
	You may wish to password protect this form if you complete this field.
109. Second Child's SSN
110. Second Child Resides with
3RD CHILD
111. Third Child's First and Middle Name:
112. Third Child's Last Name:
113. Third Child's Age:
114. Third Child's Birth date
	You may wish to password protect this form if you complete this field.
115. Third Child's SSN
116. Third Child Resides with
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4TH CHILD
117. Fourth Child's First and Middle Name:
118. Fourth Child's Last Name:
119. Fourth Child's Age:
120. Fourth Child's Birth date
	You may wish to password protect this form if you complete this field.
121. Fourth Child's SSN
122. Fourth Child Resides with
5TH CHILD
123. Fifth Child's First and Middle Name:
124. Fifth Child's Last Name:
125. Fifth Child's Age:
126. Fifth Child's Birth date
	You may wish to password protect this form if you complete this field.
127. Fifth Child's SSN
128. Fifth Child Resides with
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NOTE: You MUST click the "Submit Now" button on the bottom of this form to send your data! Be sure to complete all the sections of this form as requested by your attorney before submitting your data.
Next >> Household Budget

Expenses Income

Monthly Household Budget

To Return to Main Menu, Click Here
SINGLE SESSION -- ENTER ALL DATA ON ALL FORMS AT ONE TIME
After entering ALL data, you must click the "Submit Now" button
on the bottom of this form to send your data!

If you consider this information sensitive you may wish to password protect this file.

EXPENSES	*Press Tab Key to Move From Field to Field
(a) Housing	(Enter Monthly Amount)
1. Mortgage/Co-Op Loan
2. Home Equity Line of Credit/Second Mortgage
3. Real estate taxes
4. Homeowners/Renter's Insurance
5. Cooperative Apartment Maintenance charges/Condominium charges
6. Rent
7. Other

(b) Utilities	(Enter Monthly Amount)
1. Fuel oil
Gas
2. Electricity
3. Telephone (land line)
4. Mobile Phone
5. Cable/Satellite TV
6. Internet
7. Alarm
8. Water
9. Other

(c) Food	(Enter Monthly Amount)
1. Groceries
Lunches at work
2. Dining out
Liquor/alcohol
Home entertainment
3. Other

(d) Clothing	(Enter Monthly Amount)
1.

2. Children
Other
Laundry at home
3. Dry cleaning
4. Other

(e) Insurance	(Enter Monthly Amount)
1. Life
Homeowner's/tenant's
2. Fire, theft, and liability and personal articles policy
3. Automotive
4. Umbrella policy
5. Medical plane of insured)
5A. Medical Plan for yourself (including name of carrier and name of insured

5B. Medical Plan for children (including name of carrier and name of insured

6. Dental plan
7. Optical plan
8. Disability
9. Worker's Comp.
10. Long Term Care Insurance
11. Other

(f) Unreimbursed medical	(Enter Monthly Amount)
1. Medical
2. Dental
3. Optical
4. Pharmaceutical
5. Surgical, nursing, hospital
6. Psychotherapy
7. Other

(g) Household maintenance	(Enter Monthly Amount)
1. Repairs
Furniture, furnishings, housewares
Cleaning Supplies
Appliances including maintenance
Painting
2. Gardening/landscape
3. Sanitation/carting
4. Snow removal
5. Extermination
6. Other

(h) Household Help	(Enter Monthly Amount)
1. Domestic (housekeeper, etc.)
2. Nanny/Au Pair/Child Care
3. Babysitter
Nurse
4. Other:

(i) Automotive
1. Year: Make:
Model:	Personal (Y/N): Business (Y/N):
2. Year: Make:
Model:	Personal (Y/N): Business (Y/N):
3. Year: Make:
Model:	Personal (Y/N): Business (Y/N):
4. Year: Make:
Model:	Personal (Y/N): Business (Y/N):
5. Year: Make:
Model:	Personal (Y/N): Business (Y/N):
	(Enter Monthly Amount)
1. Lease or Loan Payments (indicate lease term)

2. Gas and oil
3. Repairs
4. Car wash
Registration/license
5. Parking and Tolls
6. Other

(j) Educational	(Enter Monthly Amount)
1. Nursery and pre-school
2. Primary and secondary
3. College
4. Post-graduate
5. Religious Instruction
6. School Transportation
7. School Supplies/Books
8. School Lunches
9. Tutoring
10. School events
11. Child(ren)'s extra-curricular and educational enrichment activities
12. Other

(k) Recreational	(Enter Monthly Amount)
1. Vacations
2. Movies
Video rentals
3. Music (Digital or Physical Media)
4. Recreation Clubs and Memberships (County Club, etc.)
5. Activities for yourself
Hobbies
Theatre, ballet, etc.
6. Health club
7. Summer camp
Team Sports
Sporting goods
Sports lessons
Music/dance lessons
8. Birthday party costs for your child(ren)
9. Other

(l) Income Taxes	(Enter Monthly Amount)
1. Federal
2. State
3. City
4. Social Security and Medicare
5. Number of dependents claimed in prior tax year
6. List any refund received by you for prior tax year

(m) Miscellaneous	(Enter Monthly Amount)
1. Beauty parlor/barber/Spa
2. Toiletries/Non-Prescription Drugs
Cigarettes/tobacco
3. Books, magazines,newspapers
Children's allowances
4. Gifts to others
5. Charitable contribution
6. Religious organization dues
7. Union and organization dues
8. Commutation and transportation
9. Veterinarian/pet exp
10. Child support payments (for Child(ren) of a prior marriage or relationship pursuant to court order or agreement)
11. Alimony and maintenance payments (prior marriage pursuant to court order or agreement)
12. Loan Payments
13. Unreimbursed business exp
14. Safe Deposit Box rental fee

(n) Other	(Enter Monthly Amount)
1.
2.
3.
4.
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GROSS INCOME INFORMATION: (Monthly Amounts)	*Press Tab Key to Move From Field to Field
If you consider this information sensitive you may wish to password protect this file.
(a) Gross (total) income:
(as should have been or should be reported in the most recent Federal income tax return. (State whether your income has changed during the year preceding date of this affidavit. If so, please explain.))
	(Enter Monthly Amount)


(b) To the extent not already included in gross income in (a) above:
	(Enter Monthly Amount)
1. Investment income, including interest and dividend income, reduced by sums expended in connection with such investment
2. Worker’s compensation (indicate percentage of amount due to lost wages)
3. Disability benefits (indicate percentage of amount due to lost wages)
4. Unemployment insurance benefits
5. Social Security benefits
6. Supplemental Security Income
7. Public assistance
8. Food stamps
9. Veterans benefits
10. Pensions and retirement benefits
11. Fellowships and stipends
12. Annuity payments

(c) If any child or other member of your household is employed, set forth name and that person's annual income	(Enter Monthly Amount)


(d) List any maintenance and/or child support you are receiving pursuant to court order or agreement
(e) Other:
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Assets and Liabilities Debts

PropertyCalc

PROPERTYCALC - ASSETS AND LIABILITIES
Category	Description	Current Value	Lien Obligation	Monthly Payment	Date Incurred
















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PROPERTYCALC - DEBTS
Category	Description	Current Debt Amount	Monthly Payment	Date Incurred

















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Are you ready to send your information to your attorney?

     CheckList:
      1. You have entered you and your attorney's Email address accurately at the top of this form.
      2. Your entries are complete as requested by your attorney.
      3. You have printed this form for your own records.
      4. Inform your attorney after you click submit so they may know your information is ready for downloading.

      Remember, this is a single session form. Enter all your information in one session, then click submit.
      Alternatively, You can begin a second session only AFTER your attorney downloads this information.

Click "Submit Now" To Send Your Data!

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