Client Information Card

To be filled out if you have already scheduled an appointment with Gordon, Tepper & DeCoursey, LLP.

Personal Information

Spouse (or other party) Information

Your Nearest Relative Information

Children Information

Social Security
Date of Birth

Addresses of the children for the last (5) years, and all the other places where child has lived, and with whom they have resided.

Child(ren) Name(s)
Present Address

Child(ren) Name(s)
Other addresses within last 5 years

Medical Plan(s) Information


Spouse (ex-spouse) or other party