Clean Break — Client Intake Form

About you

Tell us about yourself

This is the spouse who is filing for divorce — referred to as the Plaintiff in court paperwork.

Legal first name *

Legal middle name

Legal last name (current) *

Maiden / former name (if different)

Only fill in if you want to restore a former name as part of the divorce.

Date of birth *

Place of birth (city, state/country) *

Social Security Number *

Required by NYS for divorce filings. Stored securely.

Phone *

Email *

Your address

Where do you live?

This determines which Supreme Court your divorce is filed in.

Street address *

Apartment / unit (optional)

City *

ZIP *

County *

How long have you lived at this address? *

Have you lived in New York State for at least one continuous year? *

Yes No

Your spouse

Tell us about your spouse

This is the Defendant in court paperwork.

Spouse's legal first name *

Spouse's legal middle name

Spouse's legal last name (current) *

Spouse's maiden / former name (if any)

Spouse's date of birth *

Spouse's place of birth (city, state/country) *

Spouse's Social Security Number *

Spouse's phone

Spouse's email

Spouse's address

Where does your spouse live?

If they live with you, just enter the same address.

Living situation *

Same address as me Different address

Marriage details

About your marriage

Take this from your marriage certificate if you have it nearby.

Date of marriage *

City of marriage *

State / country of marriage *

Type of marriage ceremony *

Date of separation *

When did you stop living together as spouses, even if still in the same residence?

Has your marriage been irretrievably broken for at least six months? *

Yes No

Confirmations

A few yes-or-no questions

These confirm your divorce qualifies for our uncontested filing service.

Do you have any children together under the age of 21? *

No Yes

If yes, please contact us before continuing — this form is for cases without minor children.

Do you and your spouse own real estate together? *

No Yes

Do you have shared debts or significant joint assets to divide? *

No Yes

Will either spouse be requesting spousal support / maintenance? *

No Yes

Is your spouse currently pregnant? *

No Yes Not applicable

Is there an active order of protection between you and your spouse? *

No Yes

Is either spouse currently a member of the U.S. military? *

No Yes

Service preferences

How would you like to proceed?

A few last details before we wrap up.

Which package are you choosing? *

Do you want to restore your former name as part of the divorce? *

No, keep my current name Yes, restore former name

Has your spouse agreed to sign a written acknowledgment / appearance? *

Yes No Unsure

Anything else we should know?

Final step

Review and submit

Take one more look. You can go back and change any answer.

Important: By submitting, you confirm the information above is accurate to the best of your knowledge. Clean Break is not a law firm and does not provide legal advice. Use of this form does not create an attorney-client relationship.

Client intake form

Tell us about yourself

Where do you live?

Tell us about your spouse

Where does your spouse live?

About your marriage

A few yes-or-no questions

How would you like to proceed?

Review and submit

Form submitted