DIVORCE MEDIATION INCOME SURVEY
Applies to new contested divorce cases only 

Today’s Date: ________________________

Page 1 of 2

Please complete the Income Survey to determine if you qualify for a divorce mediation session (up to 4 hours) at no cost to
you (pro bono). All income surveys must be completed in full and signed in order to qualify. 

Please Complete Information for Both Parties as listed on Petition

Case #:

Judge/Commissioner:

City Where Petition was filed:

Date Petition was Answered:

PETITIONER

RESPONDENT

Full Name:____________________________________________________

Full Name:____________________________________________________

Street Address:_________________________________________________

Street Address:_________________________________________________

City, State, Zip: ________________________________________________

City, State, Zip: ________________________________________________

Date of Birth: __________________________________________________

Date of Birth: __________________________________________________

E-mail Address:_________________________________________________

E-mail Address:_________________________________________________

Phone Number(s):_______________________________________________

Phone Number(s):_______________________________________________

Attorney’s Name:_______________________________________________

Attorney’s Name:_______________________________________________

Attorney’s Address:_____________________________________________

Attorney’s Address:_____________________________________________

Attorney’s City, State, Zip: ______________________________________

Attorney’s City, State, Zip: ______________________________________

Attorney’s Phone: ______________________________________________

Attorney’s Phone: ______________________________________________

Attorney’s E-mail: ______________________________________________

Attorney’s E-mail: ______________________________________________

Is there a current Protective Order issued between the parties?  If yes, list case #: ___________________

Is there a history or allegation of domestic violence?

Are there any special needs to consider before/during the mediation?  If yes, please describe:

SECTION 1.

HOUSEHOLD INFORMATION

List yourself and all people living with you regardless of age or relationship to you.  If any person is over 18
years of age, list their monthly earnings (before taxes).

Name

Age

Relationship to You

Monthly Earnings (before taxes)

SELF

Please circle your
answers

YES

YES

YES

NO

NO

NO

 

1.

2.

3.

4.

5.

6.

7.

8.
Do you currently pay Child Support for any children?  YES_____   NO_____  If Yes, How Much? $____________ K K K 

DIVORCE MEDIATION INCOME SURVEY - Page 2 of 2 

SECTION 2.

FINANCIAL INFORMATION

A. Are you currently employed?

YES

NO

B. Do you receive Government Benefits?

YES

NO

If currently employed, please provide the following information: 

Please list the total monthly amount you receive from the following

(If not currently employed, list previous employer)

programs for everyone living in your household:

Employer: ________________________________________________

Family Employment Program: ________________________________

Address:__________________________________________________

SSI: ______________________________________________________

Phone #:__________________________________________________

Food Stamps:______________________________________________

Supervisor:________________________________________________

WIC: _____________________________________________________

Hourly Wage $:________________ # of hours per week: _________

General Assistance: ________________________________________

Refugee Cash Assistance:____________________________________

C. Do you receive other sources of income?    YES NO  

Please list the total monthly amount you receive from any of the following sources for everyone living in your household:

Alimony: ______________________________

Social Security Benefits: _________________________

Child Support:__________________________

Unemployment Compensation:____________________

Disability Benefits:______________________             Worker’s Compensation:__________________________                                            

Other: (please specify) __________________                

02/12/15

This section must be signed in order to process the income survey. Incomplete surveys will not be accepted.

I verify under the penalties of perjury that the information provided on this income survey is true and correct, and that if
any of the financial information changes, I will inform the Divorce Mediation Program immediately.

_________________________________________________
Signature

_________________________________________________
Date

WHERE TO SEND THE SURVEY

ECTION 4.

  S

SECTION 3.

STATEMENT OF VERIFICATION

NOTE: Please remember to complete all sections of this form --- Incomplete surveys will not be processed.
Please print out the Income Survey and sign it before returning it to:

Bart MacKay
Divorce Mediation Program Coordinator
Administrative Office of the Courts
206 W. Tabernacle, Suite 160
St. George, Ut 84770

Phone: (435) 986-5754
E-mail: divorceinfo@utcourts.gov                                              
Toll Free Automated Helpline: 1-800-620-6318
Website: www.utcourts.gov/mediation/divmed