[NOTE: The following sample questionnaire is used with the New York Separation Agreements Library. If you ordered the library for some other jurisdiction, some of the questions and terms would be different.]


Name of Husband:
[OR __a same-sex relationship -- between __two females __two males
a same-sex marriage, civil union or domestic partnership created in:

Phone No.:

Soc. Sec. No.:
Estimate Annual Income: $
Estimated Assets (range):
Military Status:
Advisors (accountant, insurance agent, physician, investment advisor, banker, clergyman):

Name of Wife:
Maiden name:
Phone No.:

Soc. Sec. No.:
Estimate Annual Income: $
Estimated Assets (range):
Military Status:
Advisors (accountant, insurance agent, physician, investment advisor, banker, clergyman):

You represent __Husband / __Wife

__other spouse has an attorney - name, address, phone no.:

Place of marriage:
Date of marriage:

__prepare A Stipulation of Settlement rather than a Separation Agreement
Plaintiff is __Wife / __Husband
__Defendant in military
__an answer has been filed
Name of Court:
Index/Case No.:
__no children __1 __2 Number: ___
Name(s) and age(s) and whether minor (unemancipated):

CUSTODY of minor children -
__Wife to have custody
__Husband to have custody
__joint custody
__but children reside with Wife
__but children reside with Husband
__without residing predominantly with either
__Agreement to be silent on subject

__recite that upon death of custodial parent, non-custodial parent shall have custody
__non-custodial parent to pay specific amounts for child support for each child -
$________ __weekly/ __biweekly/ __monthly/ __other:
Payments to end (if the child is NOT attending college) at age __18/ __21/ __other:
But if the child is ATTENDING COLLEGE payments to end at __22 __the same age as if not attending college __some other age:
__non-custodial parent to pay "reasonable" amounts
__no child support to be sought
__payments increase with Consumer Price Index (CPI)
__payments increase on specific dates - dates and payments:

Re payments for college -
__non-custodial parent to make additional payments while children in college -
$________ per _________ per child
__non-custodial parent to pay into a college fund -
$________ per _________ per child
__both parties to pay to college fund -
Husband - $________ per _________ per child
Wife - $________ per _________ per child
__non-custodial parent to pay __all/ __one-half of the college expenses - __but not more than __$________ per annum per child, or __cost of attending:
__college payments increase with CPI
__child support DEVIATES from PRESUMPTIVE AMOUNT: $
__non-custodial parent may claim tax exemptions for children
__non-custodial parent to have visitation rights pursuant to a specific schedule
__Sat or Sun weekly vs __ Sat & Sun biweekly
__Christian vs __Jewish holidays
How many weeks in summer: [__consecutive]
__non-custodial parent to have "reasonable" visitation
__visitation for non-custodial parent not to be discussed
__"reasonable" visitation rights for grandparents
__no restrictions
__visitation rights shall be adjusted
__moving from New York prohibited
__moving more than _____ miles prohibited
__other restrictions:

Restrictions on moving to terminate -
__when children reach majority
__on a specific date:
__remarriage of custodial parent
__health of custodial parent requires move
__Agreement to be silent re termination
__Husband to pay specific amounts to Wife
$________ __weekly __biweekly __monthly __other:
__Husband to pay "reasonable" amounts
__no maintenance to be provided [__but Wife expressly may later apply to a court for maintenance]
__payments to terminate on specific date (other than death/remarriage) - date:
__payments increase with CPI
__payments increase on specific dates - specify:
MARITAL RESIDENCE (occupied prior to separation) -

The marital residence was -
__an apartment
__a __house/__condo/__coop owned by BOTH parties
__a __house/__condo/__coop owned by Husband
__a __house/__condo/__coop owned by Wife
__rented premises (other than an apartment)
Legal title to be
__transferred to Husband and Wife as tenants in common
__transferred to Wife
__transferred to Husband
__left unchanged
__transferee to pay lump sum for transferor's interest: $
__transferor to continue to pay expenses of marital residence - describe:

Possession of marital residence to be given to -
__marital residence is to be sold -
__but Wife may reside until the sale
__but Husband may reside until the sale
__neither may reside
__marital residence to be sold only if party in possession -
__vacates __remarries __cohabits with adult __children emancipated
Proceeds of sale of marital residence to be paid -
__equally by Husband and Wife
__to Wife
__to Husband
__$________ to Wife, balance to Husband
__$________ to Husband, balance to Wife

__a minimum acceptable sales price: $
Is marital residence affected by -
__an existing mortgage or similar instrument
__insurance premiums
__real estate taxes
__condo [__coop] charges or fees

These are to be paid by -
__Husband and Wife in equal shares
Minor repairs [__less than $________] to be paid by -
__parties equally
__Agreement to be silent on subject
__there is OTHER REAL ESTATE, the rights to which should be set forth in Agreement - describe property and rights:

__there are marital debts to be listed and paid -
__by Husband
__by Wife
__some by Husband and some by Wife:

__there are accounts containing funds
Approx. amount: $
To be paid to -
__Husband and Wife equally
__in some other fashion:
__some accounts have been drained by __Husband / __Wife
__Husband to pay Wife $________ to settle claims
__Wife to pay Husband $________ to settle claims
__all such claims are waived
__Agreement to be silent on subject
Identify the accounts:

__parties filed joint returns for prior year
__parties are GOING TO file joint returns
Refunds are to be paid to -
__parties equally
__in proportion to income
__Agreement to be silent on subject
Any deficiency (or taxes due) are to be paid by -
__parties equally
__in proportion to income
__party who caused the deficiency
__Agreement to be silent on subject
AUTOMOBILES - identify autos, who gets them (and any provision re expenses of autos):

Husband is to -
__maintain existing insurance
__maintain existing insurance and increase coverage
__procure new insurance (none exists)
__Agreement to be silent on subject

Amount of existing insurance: $
Amount of additional insurance to be procured: $
Total insurance to be maintained: $

The life insurance is to be for the benefit of -
__Wife, or if she dies children
__just Wife
__just children
__Wife to pay portion of insurance premiums - amount or share:

__Husband to maintain medical insurance for benefit of -
__Wife and children [__just minor children]
__just Wife
__just children [__just minor children]

__Husband to maintain "major medical" insurance (in addition to basic coverage)
__Husband need not maintain insurance if Wife's employer provides coverage
__requirement for insurance to end on a specific date:

Re the deductible under medical insurance -
__Husband pays deductible
__he pays half the deductible
__he pays some other portion:
__Wife (not Husband) pays deductible
__Agreement to be silent on subject
Should the same rule apply to -
__dental and orthodontic expenses
__all medical expenses not covered by insurance
If not, is anything to be provided:
__Husband can freely dispose of his estate
__Husband must bequeath $________ to Wife, or if she dies to children
__Husband must bequeath ___% of his estate to Wife, or if she dies to children
__Husband must bequeath $________ to children directly
__Husband must bequeath ___% to children
__requirement ends on a specific date:
__Wife to be subject to same requirement as to her estate

__prepare a short form (easier to negotiate)

Month in which Agreement will be executed:

__other LUMP SUM PAYMENT to be made by __Husband / __ Wife - $

__Husband to pay Wife a portion of a PENSION PLAN
Company providing plan:
Wife's share - __50% / __other: ___% / __ formula based on duration of employment and marriage
__Agreement to contain representations re NET WORTH and INCOME
Husband's approx. income: $________
Husband's net worth: between $________ and $________
Wife's approx. income: $________
Wife's net worth: between $_______ and $________
__(if you represent Wife) Husband is to pay your fee: $

__if there is a material change in economic circumstances, either party may apply to a court for modification

__disputes to be resolved by arbitration - where:

__a previously executed prenuptial agreement is to be superseded - date of agreement:

Also prepare: __Memorandum of Agreement / __Financial Statements / __Deed to marital residence