Minnesota Petition For Dissolution of Marriage With Children

State of Minnesota
District Court
Judicial District:
County of
Court File Number:
Assigned Judge:
Case Type:
Dissolution with Children
In Re the Marriage of:
Petition For Dissolution Of
Marriage With Children
Name of Petitioner (first, middle, last)
and
Name of Respondent (first, middle, last)
STATE OF MINNESOTA
)
COUNTY OF
)SS
(County where Petition is signed)
1. Information about Petitioner
Full Name: ________________________________________________________________________
First
Middle
Last
Address where you live:
Street Address
Apt. No.
_______
City
County
State
Zip Code
Mailing address where you agree to receive papers for this case:
Same as above address OR
________________________________________________________________________
Street Address
Apt. No.
_______
City
County
Date of Birth: ________________________
Month
Day
State
Petitioner is the
Zip Code
husband
wife.
Year
List all of Petitioner’s former or other names or write “None”:
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2.
Information about Respondent
Full Name:
First
Middle
Last
Address:
Street Address
Apt. No.
City
County
State
Zip Code
Respondent's address is unknown to Petitioner.
Respondent’s Date of Birth: ________________________
Month
Day
Year
List all of Respondent’s former or other names or write “None”:
3.
First
Middle
Last
First
Middle
Last
Our Marriage
Petitioner and Respondent were married on: (month, day, year)
,
in the City of _____________________, County of _______________________________, State of
__________________________, Country of
4.
.
180 Day Requirement
Has Petitioner been living in Minnesota for the past six (6) months?
YES
NO
Has Respondent been living in Minnesota for the past six (6) months?
YES
5.
NO
UNKNOWN
Armed Forces
Is Petitioner an active duty member of the armed forces?
YES
NO
If YES, has Petitioner been stationed in Minnesota for the past six (6) months?
YES
Is Respondent an active duty member of the armed forces?
Unknown
YES
NO
If YES, has Respondent been stationed in Minnesota for the past (6) months?
6.
NO
YES
NO
Marriage Cannot be Saved
There has been an irretrievable breakdown of my marriage relationship with Respondent and
the marriage cannot be saved.
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7.
Physical Living Situation
Do Petitioner and Respondent live together at this time?
YES
NO
If NO, the date we separated was:
.
Month
Day
Year
If YES, why are you living together at this time?
8.
Other Proceedings
a. Has a separate court case for marriage dissolution, legal separation, custody, paternity or
annulment already been started by Petitioner or Respondent in Minnesota or elsewhere?
NO
YES
If YES, the type of court case is:
,
and it was started in ________________________ County in the State of ____________________
and the Court file number is
Open
Closed
, and the status or outcome of the case is:
I do not know
b. Has a County started a Support case involving the Petitioner and the Respondent or their
children?
YES
NO
If YES, the case was started in ________________________
County in the State of ____________________ and the Court file number is
A copy of the Support Order is attached, or the case is
9.
Dismissed, or
.
Pending.
Protection or Harassment Order
Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and
Respondent?
YES
NO
If YES:
a. The Order protects:
Petitioner
Respondent
in
the child(ren) and the Order was filed
County in
State on
date, and the Court file number is
. A copy of the
Order is attached.
b. Does the Order for Protection include an order to pay child support?
10.
YES
NO
Juvenile Court Case
Is a Juvenile Court case (child protection, delinquency or foster care) involving husband's and wife’s
child(ren) taking place in Minnesota or another state?
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YES
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NO
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If YES, the case is in
County in the State of __________________ and the
Court file number is
. The name of the child or children involved
in the Juvenile Court case is:
.
11.
Children Husband and Wife have Together (Joint Children)
“Child” means a living person under age 18, or under age 20 and still in high school.
a. Are there any children born to or adopted by husband and wife together, either before or during
the marriage?
YES
NO
If YES,
Full Name of Child Date of Birth Age
Child Currently Lives With
Petitioner
Respondent
Both parents
OR
_______________________(write in name)
Petitioner
OR
Both parents
Respondent
Both parents
________________________(write in name)
Petitioner
OR
Respondent
________________________(write in name)
Petitioner
OR
Both parents
________________________(write in name)
Petitioner
OR
Respondent
Respondent
Both parents
________________________(write in name)
If a child is living with someone other than a parent, write the child's address below:
Address:
______________________________________________________________________
Street Address
Apt. No.
City
County
State
Zip Code
b. Has each child born to or adopted by husband and wife together lived in Minnesota for the past
six (6) months?
YES
NO
If NO, name the child or children, name the State(s) the child has lived in during the past 6
months, and the dates the child lived in each state:
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12.
Adult Dependent Children
Support can be ordered for a joint child over age 18 who cannot support him/herself because of a physical or mental
condition.
Is there an adult joint child born to or adopted by Husband and Wife who is not able to support
himself or herself because of a physical or mental condition?
YES
NO
If YES, the full name, date of birth and age of each adult dependent is:
Full Name of Dependent
Date of Birth
13.
Age
Pregnancy
a.
Petitioner
b.
Is wife pregnant?
Respondent is the wife in this marriage.
YES
NO
UNKNOWN
If wife is pregnant answer (i) and (ii):
(i) The date the baby is due is
OR
Month
Day
UNKNOWN
Year
(ii) Do Wife and Husband agree that husband is the biological father of the unborn child?
YES
NO
If NO,
Wife
Husband claims husband is not the biological father of the child,
and Petitioner asks the Court to issue a separate order setting a hearing date for after
the birth of the child to determine Paternity, unless appropriate Recognition of
Parentage documents are signed by husband, wife and the biological father after the
birth of the child.
14.
Husband’s Children from Other Relationship (Non-Joint Children)
Does Husband have minor child(ren) from another marriage or relationship?
YES
NO
UNKNOWN
If YES, the full name, date of birth and age of each child is:
Full Name of Child
and Age
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Does Child Live
with Husband?
YES
NO
Is Husband Court-Ordered to pay
Child Support for this Child?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
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15.
Wife’s Children from Other Relationship (Non-Joint Children)
a. Does Wife have minor child(ren) born prior to the marriage from another marriage or
relationship?
YES
NO
UNKNOWN
If YES, the full name, date of birth and age of each child born prior to the marriage is:
Full Name of Child
and Age
Date of
Birth
Does Child Live
with Wife?
YES
NO
Is Wife Court-Ordered to pay
Child Support for this Child?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
b. Has Wife given birth, since marrying Husband, to a minor child who is not a
child of the Husband?
YES
NO
If YES, answer (i) , (ii), (iii) and ( iv):
(i) List the full name, date of birth and age of each child born to Wife since marrying
Husband, who is not a child of the Husband:
Full Name of Child
and Age
Date of
Birth
Does Child Live
with Wife?
YES
NO
YES
(ii)
Is Wife Court-Ordered to pay
Child Support for this Child?
YES
NO
NO
YES
NO
Is there a Court Order naming someone other than the Husband as the father of the
child(ren) listed in (i) above?
YES
NO
If YES, attach a copy of the Order. The Order is for: _______________________
Full Name of Child(ren)
(iii)
Have the Wife and biological Father signed a Minnesota Recognition of Parentage
for any of the children listed in (i) above?
YES
If YES, state the full name of the child:
NO
and
attach a copy of the Recognition of Parentage.
If NO, why not?
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Has the Husband signed the “Husband’s Non-Paternity Statement ” for any of the
(iv)
children listed at (i) above?
YES
NO
If YES, state the name of the child:
and attach a copy of the "Husband's Non-Paternity Statement."
If NO, why not?
16. Parenting Time
Petitioner's parenting time with the joint children should be: (check one)
unsupervised
supervised
reserved
Respondent's parenting time with the joint children should be: (check one)
unsupervised
supervised
reserved
If parenting time is unsupervised for both parents, skip to Question 17.
For supervised parenting time answer a. and b. For reserved parenting time, answer c.
a. Explain how unsupervised parenting time is likely to endanger the child's physical or
emotional health or impair the child's emotional development:
b. State who should supervise parenting time, and if there is a cost involved, who should pay
the cost, and any other important details:
c. Explain why parenting time should be reserved:
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17.
Public Assistance from State of Minnesota
If either party is receiving public assistance from the State of Minnesota or applies for it after this
proceeding is started, the Petitioner must give notice of this marriage dissolution action to the Support and
Collections office for the county paying the assistance.
a. Does Petitioner receive public assistance from the State of Minnesota?
YES
NO
If YES, the assistance is from __________________ County. (Check all that apply):
MFIP in the amount of $___________per month
Tribal TANF in the amount of $__________per month
General Assistance in the amount of $___________per month
Child Care Assistance
MinnesotaCare
Medical Assistance
b. Does Respondent receive public assistance from the State of Minnesota?
YES
NO
UNKNOWN
If YES, the assistance is from __________________ County. (Check all that apply):
MFIP in the amount of $___________per month
Tribal TANF in the amount of $__________per month
General Assistance in the amount of $___________per month
Child Care Assistance
MinnesotaCare
Medical Assistance
c. Do the joint children of the parties receive public assistance from the State of Minnesota?
YES
NO
UNKNOWN
If YES, the assistance is from __________________ County. (Check all that apply):
MFIP
Medical Assistance
Tribal TANF
MinnesotaCare
IV-E Foster Care
18.
Supplemental Security Income (SSI)
Supplemental Security Income (SSI) is a Federal income supplement program. It is available to low-income people
if they are over age 65, or blind, or disabled.
a.
Does Petitioner receive Supplemental Security Income (SSI)?
NO
YES in the amount
of $___________per month.
b.
Does Respondent receive Supplemental Security Income (SSI)?
NO
YES in the
amount of $___________per month.
c.
Do any of the joint children of the parties receive Supplemental Security Income (SSI)?
NO
YES in the amount of $___________per month. What is the name of the child
Receiving SSI?____________________________________________________________
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19.
School
Is Petitioner currently enrolled in school?
YES
NO If Yes:
a. The name of the school is
b. The type of school is
.
High School
College
Vocational
Other
c. The type of degree expected is____________________________and the expected
graduation date is __________________________.
Is Respondent currently enrolled in school?
YES
NO
UNKNOWN If Yes:
a. The name of the school is
b. The type of school is
.
High School
College
Vocational
Other
c. The type of degree expected is____________________________and the expected
graduation date is __________________________.
20.
Petitioner’s Employment
a. Is Petitioner employed?
YES
NO
Is Petitioner Self-Employed?
b. Is Petitioner working at least 40 hours per week?
YES
YES
NO
NO
If you are unemployed or working less than 40 hours/week, answer these questions:
i. Explain why you are not working or why you work less than 40 hours/week.
ii. What is your past work experience (type of jobs, hours, pay, length of time at the job) and what are
your professional qualifications or licenses?
c.
Current Employment: (If Petitioner has more than two jobs at this time, use an attachment for the additional jobs.)
____________________________________________________________________________
Name of Petitioner’s Employer (If Self-Employed, list name and business address)
____________________________________________________________________________
Employer’s Street Address
City
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Name of Petitioner’s Employer (If Self-Employed, list name and business address)
____________________________________________________________________________
Employer’s Street Address
____________________________________________________________________________
City
State
Zip Code
1st Job
Questions about Current Jobs
Are you paid by the hour or do you
hourly
2nd Job
salary
hourly
salary
have a salary?
What is the average number of hours
you work per week?
________________hours
________________hours
receive per week on average?
$_____________________
$____________________
Do you receive bonuses?
If Yes, how much did you receive in If Yes, how much did you receive in
How much overtime pay do you
Yes
No
bonuses last year? $_____________
bonuses last year? $_____________
How much do you expect to receive How much do you expect to receive
this year? $___________
this year? $___________
21. Petitioner’s Income
NOTE: There is a separate form called "Financial Affidavit" which you must fill out, serve on your
spouse, and file with the court at the time you file this Petition. You must attach proof of your
income to the Financial Affidavit.
If you do not have income in a category, enter zero (0). Do not list public assistance benefits as income (e.g.
MFIP, GA, SSI).
Source of Income
Amount Per Month (before deductions/taxes)
Self Employment Income
$________________ (or zero)
Self Employment income means gross receipts minus costs of goods sold minus ordinary and
Necessary business expenses. Attach Schedule "C" from last year's tax return to this Petition.
Job with __________________________
$________________per month
Your monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)
Second Job with _____________________
$________________ per month
Third Job with ______________________
$________________ per month
Commissions from all jobs
$________________ per month
Divide the total amount you expect this year by 12 to get a monthly average
Unemployment benefits
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$________________ per month
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Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI)
$_________________per month
Investment and Rental Income
$________________ per month
Annuity payments
$________________ per month
Pension or Disability from work or military
$________________ per month
Worker's Compensation
$________________ per month
Court-ordered spousal maintenance you receive
$________________ per month
Other income____________________________
$________________ per month
Identify Source
Add all of the above. Total monthly income
$ ________________ per month
Enter the amount of child support you are court-ordered
to pay for any nonjoint child(ren)
$________________per month
Enter the amount of spousal maintenance you are court-ordered
to pay to your current or former spouse
$_______________per month
Enter the amount of Social Security or Veteran's Benefits provided to a joint child because of
your retirement, disability, or other eligibility
$________________ per month
If you entered an amount, which parent receives the payment for the child?
Petitioner
Respondent
22.
Living Expenses for the Family
a. Petitioner and Respondent and our children are still living together. Our current monthly
living expenses for our family total $
.
OR
b. Petitioner and Respondent are living separately. Our monthly family living expenses before
we separated totaled $
. At this time, Petitioner's separate monthly
living expenses total $____________, and Respondent's monthly living expenses total
$______________or
are unknown to Petitioner. Of the total current monthly living
expense for Petitioner, what dollar amount is for expenses just for the children that live with
Petitioner?
$_________________.
Of the total current monthly living expenses for
Respondent, $___________is for expenses just for the children that live with Respondent, or
this is UNKNOWN.
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23. Expenses for Special Needs for the Children
a. Is there a child of the parties who has special needs and extraordinary medical expenses?
YES
NO If Yes,
Name of child with special needs:
Describe the needs:
b. Does Petitioner’s monthly living expense (stated at #22) include the special needs expenses for
the child?
YES
NO
c. Does Respondent’s monthly living expense (stated at #22) include the special needs expenses
for the child?
24.
YES
NO
Respondent’s Employment
a. Is Respondent employed?
YES
b. Is Respondent Self-Employed?
NO
YES
UNKNOWN
NO
c. Is Respondent working at least 40 hours per week?
UNKNOWN
YES
NO
UNKNOWN
If Respondent is unemployed or works less than 40 hours/week, answer these questions:
i. Explain why Respondent is not working or why Respondent works less than 40 hours/week
ii. What is Respondent's past work experience (type of jobs, hours, pay, length of time at the job)
and professional qualifications or licenses?
c. Current Employment: (If Respondent has more than two jobs at this time, use an attachment for the additional jobs.)
____________________________________________________________________________
Name of Respondent’s Employer (If Self-Employed list name and business address)
____________________________________________________________________________
Employer’s Street Address
____________________________________________________________________________
City
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___________________________________________________________________________
Name of Respondent’s Employer (If Self-Employed list name and business address)
____________________________________________________________________________
Employer’s Street Address
City
State
Zip Code
1st Job
Questions about Jobs
2nd Job
Is Respondent paid by the hour or
hourly
salary
salaried?
Unknown
hourly
Unknown
What is the average number of hours ________________hours
Respondent works per week?
salary
________________hours
Unknown
Unknown
How much overtime pay does
Respondent receive per week on $_____________________
average?
$____________________
Unknown
Does Respondent receive bonuses?
Yes
No
Unknown
Unknown
If Yes, how much did Respondent If Yes, how much did Respondent
receive
in
bonuses
last
year? receive
$___________
in
bonuses
last
year?
$_________
How much does Respondent expect How much does Respondent expect
to receive this year? $___________
to receive this year? $___________
Respondent’s Income
25.
Petitioner has no information about Respondent's income
OR
Petitioner does not have detailed information about Respondent's income, but has good
reason to believe that Respondent's pay is $________________ per
week
month
year, with bonuses, overtime or commissions in the additional amount of
$________________ per
week
Income (after taxes and deductions) or
month
year. This is Respondent's
Net
Gross Income (before taxes and deductions.)
OR
Petitioner has detailed information about Respondent's income. If this is true, fill out the
income information below.
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If Respondent has no income in a category, enter zero (0). Do not list public assistance benefits as income
(e.g. MFIP, GA, SSI).
Respondent's Source of Income
Amount Per Month (before deductions/taxes)
Self Employment Income
$___________________ (or zero)
Self Employment Income means gross receipts minus costs of goods sold minus ordinary and
necessary business expenses. Attach Schedule C from last year's tax return to this Petition, if available.
Job with______________________________
$ ___________________ per month
Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)
Second job with________________________
$____________________ per month
Commissions from all jobs
$____________________ per month
Divide the total amount expected this year by 12 to get a monthly average
Unemployment benefits
$____________________ per month
Social Security Retirement, Survivors or Disability Income (RSDI)
(do not include SSI)
$____________________ per month
Investment and Rental Income
$____________________ per month
Annuity payments
$_____________________ per month
Pension or Disability from work or military
$_____________________ per month
Worker's Compensation
$_____________________ per month
Court-ordered spousal maintenance received
by Respondent
$____________________ per month
Other income____________________________
$____________________ per month
Identify Source
Add all of the above.
Total monthly income
$ ____________________ per month
Enter the amount of child support Respondent is court-ordered to
pay for any nonjoint child(ren)
$____________________ per month
Enter the amount of spousal maintenance Respondent is court-ordered
to pay to a current or former spouse
$____________________ per month
Enter the amount of Social Security or Veteran's Benefits provided to a joint child because
of Respondent's retirement, disability, or other eligibility
$_____________________ per month
If you entered an amount, which parent receives the payment for the child?
Petitioner
Respondent
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26.
Child Care Costs
Are there child care costs for the joint children because of work or school?
YES
NO
If YES, attach to this Petition a receipt or signed letter from the child care provider showing the
cost of child care, and answer (a) (b) and (c):
a. How many of your joint children need child care?
One
Two
Three
__________
b. How much does the daycare center(s) or babysitter charge per month? $
(If you pay by the week, multiply the weekly charge by 4.33 to get the charge per month. If costs vary during the
year, use the total yearly costs and divide by 12.)
c.
Who pays the child care costs?
Petitioner pays $
per month
Respondent pays $
per month
The County pays $
per month through a subsidy or child care
assistance.
If the County pays, who applied for the child care assistance?
Petitioner
Respondent
There is no county assistance
27.
Health Care Coverage
a. Minnesota Care and Medical Assistance are available from the State of Minnesota for people
who qualify. Who receives Minnesota Care or Medical Assistance?
Petitioner
Respondent
Joint Children
No one
b. Does Petitioner currently have medical insurance? (other than MN Care or Medical Assistance)
Yes
No. If no, skip to c.
i. Where does Petitioner get the medical insurance?
through his/her employment
buys private medical insurance
ii. How much does the medical insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
iii. Who is currently covered by this medical insurance?
Petitioner
Respondent
All the Joint Children
Some of the Joint Children:
Name the joint children who are covered_____________________________________
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c. Does Petitioner have dental insurance? (other than MN Care or Medical Assistance)
Yes
No. If no, skip to d.
i. Where does Petitioner get the dental insurance?
through his/her employment
buys private dental insurance
ii. How much does the dental insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
Or,
Dental is included in the medical insurance costs.
iii. Who is currently covered by this dental insurance?
Petitioner
Respondent
All the Joint Children
Name the joint children who are covered____________________________________
Some of the Joint Children:
Nonjoint children
d. Does Respondent have medical insurance? (other than MN Care or Medical Assistance)
Yes
No
Unknown. If No/ Unknown, skip to e.
i. Where does Respondent get the medical insurance?
through his/her employment
buys private medical insurance
ii. How much does the medical insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
iii. Who is currently covered by this medical insurance?
Petitioner
Respondent
All the Joint Children
Name the joint children who are covered____________________________________
Some of the Joint Children:
Nonjoint children
e. Does Respondent have dental insurance? (other than MN Care or Medical Assistance)
Yes
No
Unknown If No/ Unknown skip to f.
i. Where does Respondent get the dental insurance?
through his/her employment
buys private dental insurance
ii. How much does the dental insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
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$____________per month for family coverage
Or,
Dental is included in the medical insurance costs.
iii. Who is currently covered by this dental insurance?
Petitioner
Respondent
All the Joint Children
Some of the Joint Children:
Name the joint children who are covered_____________________________________
Nonjoint children
f. If the joint children are without health care coverage, is coverage available for purchase through
Petitioner's or Respondent's employer?
YES
NO
The children currently have health
coverage
28.
Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.
Check only one box:
Petitioner and Respondent can each pay their own living expenses and do not need spousal
maintenance at this time, or in the future.
Petitioner or Respondent may need spousal maintenance in the future. The court should reserve
maintenance to allow either party to ask for spousal maintenance in the future because:
(explain why you want to do this)
Petitioner needs spousal maintenance from Respondent now. Petitioner is __________years
of age, Petitioner and Respondent have been married for _________years. Petitioner has the
following education:_____________________________________________. Petitioner’s
gross monthly income totals $__________________. Petitioner’s monthly expenses total
$______________ and Petitioner is not able to maintain the standard of living established
during the marriage because:
_______________________________________________________
Respondent has the ability to pay Petitioner $_____________per month for spousal
maintenance.
Respondent needs spousal maintenance from Petitioner now. Respondent is __________years
of age, Petitioner and Respondent have been married for _________years. Respondent has the
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following education:_____________________________________________. Respondent’s
gross monthly income totals $______________. Respondent’s monthly expenses total
$________________, and Respondent is not able to maintain the standard of living established
during the marriage because: _______________________________________
.
Petitioner has the ability to pay Respondent $_____________per month for spousal
maintenance.
29. Vehicles
Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles etc.
owned by husband or wife together or separately, including vehicles purchased after separation:
Does Petitioner own a vehicle?
YES
Does Respondent own a vehicle?
NO
YES
NO
UNKNOWN
List all vehicles owned by husband or wife together or separately:
Type of
Vehicle (car,
boat, truck etc.)
30.
Year/Make/
Name(s) on
Model
Title
Value
Balance Owed
Monthly
Payment
$
$
$
$
$
$
$
$
$
$
$
$
Marital Property
Marital property means almost anything that you or your spouse now own that was received or bought during
the marriage, even during the times you were separated. Marital Property includes household goods,
furniture, jewelry, boats, real estate and other things. Marital property does not include a gift or inheritance
received by one spouse alone.
Has the marital property been divided already to the Petitioners’ satisfaction?
YES
NO
If NO, Petitioner requests the following marital property:
________________________________________________________________________________
________________________________________________________________________________
31.
Non-Marital Property
Non-marital property means: (1) anything that you or your spouse owned before the marriage; (2) anything
that you or your spouse received as a gift, bequest, devise, or inheritance, to you or your spouse alone; (3)
anything that you or your spouse got in trade or in exchange for your non-marital property; (4) anything that
is an increase in the value of non-marital property; (5) anything you or your spouse received after the
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valuation date set by the court; or (6) anything defined as non-marital property by a valid antenuptial
contract.
a.
Does Petitioner have non-marital property?
YES
NO
If YES, list Petitioner’s non-marital property:
b.
Does Respondent have non-marital property?
YES
NO
UNKNOWN
If YES, list Respondent’s non-marital property:
___________________________________________________________________________.
32.
Cash & Accounts – Not including Pension and Employer-Funded Retirement Accounts
Does Petitioner have money in banks, savings, cash or investments?
YES
Does Respondent have money in banks, savings, cash or investments?
YES
NO
NO
UNKNOWN
If YES,
a.
List all accounts owned by you alone, your spouse alone, or owned by both of you jointly
including those opened after separation. “Type of account” means checking, savings, money market
accounts, certificates of deposit, stocks, bonds, stock options, mutual funds, savings bonds, and
Treasury Bills, etc.
Do not include Pension or Employer-Funded Retirement Accounts, which are listed at #36.
Financial
Type of Account
Account #
Amount
(name on account)
Last 4 digits only
Institution
Belongs to:
XX
$
XX
$
XX
$
XX
$
XX
$
XX
$
b. List cash not listed at a.:
33.
Petitioner has cash in the amount of $
.
Respondent has cash in the amount of $
OR
UNKNOWN.
Business Interest
Does Petitioner have an interest in a business?
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NO
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Does Respondent have an interest in a business?
YES
NO
UNKNOWN
If YES, the name of the business is ____________________________, the address is
________________________________________________________________________________
and the value is $________________. How did you arrive at this value?
34.
Manufactured Home
Does Petitioner own a manufactured home?
YES
NO
Does Respondent own a manufactured home?
YES
NO
UNKNOWN
If either Petitioner or Respondent own a manufactured home, together or separately, complete
the following information:
a. Address of the manufactured home:
in the city of
, state of
b. What type of home is it? (single, double-wide etc.)
c. Whose name(s) is on the title?
d. When was the home purchased?
e.
What was the purchase price?
$
f. What is the current values of the home? $
g. How did you arrive at that amount as the current value?
h. How much money is still owed on the home? $
i. If money is owed on the home, who is the money owed to?
j. Do you own the land the home sits on, or do you rent a lot?
Rent
Own
Note: If you own the lot, you must list the land at Paragraph 35.
35. Real Property - Land, Buildings, Contracts for Deed
All real property now owned by Petitioner or Respondent together or separately must be listed. Include real
property acquired before the marriage, during the marriage, and after separation.
a.
Do Petitioner and Respondent jointly own real property?
b.
Does Petitioner own real property solely in his/her own name or with someone other than
Respondent?
b.
NO
NO
Does Respondent own real property solely in his/her own name or with someone other than
Petitioner?
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NO
UNKNOWN
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c.
How many properties are owned by you and your spouse in total?
Three
None
One
Two
_______
If you or your spouse own real property, separately or together, complete the following
information about the property. If there is more than one piece of real property, photocopy
and complete a Real Property Information page for each piece of property.
Staple the
additional sheets to this Petition, and label each sheet "Attachment to Petition of
____________________(your name)"
Real Property Information
1. Real Estate belongs to: (List full names of all owners)_____________________________________
________________________________________________________________________________
2. Legal Description is: (The full legal description must be included. Copy the legal description from
the deed. Do not use the property tax statement legal description. If the legal description is long,
you may use an attachment. Type or print neatly.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3. Street Address of the real property is:
________________________________________________________________________________
City______________________________________State______________Zip Code______________
The property is in_____________________________________County.
4. Purchase date_________________(month , day, year) and purchase price:$
_______
5. Mortgages or loans: (List all mortgages and loans on the property)
There are no mortgages or loans on this property.
1st Mortgage: Amount currently owed $
and name of lender
2nd Mortgage: Amount currently owed $
and name of lender
Other mortgages or loans:
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6. Current Market Value of this property:
$___________________________________
How did you arrive at this value?
7. This property is the homestead: _______Yes
36.
_________No
Retirement Plans
a.
Does Petitioner have a retirement account? (IRA, 401(k), 403(b) or other)
YES
NO
If YES:
a) The account number is: (last 4 digits only)
b) The name of the bank that has the account is:
c) The current account balance is:
b.
Has Petitioner, or Petitioner’s past or present employer, union, or other group, paid money
into a pension, profit sharing, or other retirement plan for Petitioner?
YES
NO
If YES:
a) The name of the plan is:____________________________________________________
b) The employer, union or group providing the plan is:
c) The date Petitioner began working at the job or joined the union or group plan is:
d) The type of plan is: (e.g. defined benefit, defined contribution)
e) The present value of the pension or plan is:
c.
Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other)
YES
NO
UNKNOWN
If YES:
a) The account number is: (last 4 digits only)
b) The name of the bank that has the account is:
c) The current account balance is:
d.
Has Respondent, or Respondent’s past or present employer, union, or other group, paid
money into a pension, profit sharing, or other retirement plan for Respondent?
YES
NO
UNKNOWN
If YES, and it is a Pension, Profit-Sharing, or other Retirement Plan:
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a) The name of the plan is:
b) The employer, union or group providing the plan is:
c) The date Respondent began working at the job or joined the union or group plan is:
d) The type of plan is: (e.g. defined benefit, defined contribution)
e) The present value of the pension or plan is: ___________________________________
37.
Debts
Does Petitioner have debt?
YES
NO
Does Respondent have debt?
YES
NO
UNKNOWN
If YES, list debts in your name, your spouse’s name and in both names jointly. Include unpaid
debts from before the marriage date, during the marriage, and after separation. Fill in all
information completely and attach another sheet of paper if necessary.
Money is owed
to:
Money was used Whose Name is on the Account
for:
and When was the Debt
Incurred?
Name
Date
Total Debt
38.
Balance
Owed
Monthly
Payment
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Name Change
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Does Petitioner want to change his/her name?
YES
NO If YES, answer (a) through (c)
below:
Petitioner’s name should be changed to
a.
First
Middle
Is this name a former legal name or maiden name?
YES
NO
Last
If NO, the reason
Petitioner wants to change to this name is: _________________________________________
____________________________________________________________________________
____________________________________________________________________________
b.
Petitioner has no intent to defraud or mislead anyone by changing his/her name:
True
c.
False
Has Petitioner been convicted of a felony?
YES
NO
If YES, answer i. and ii:
i. Petitioner has given notice of this request for name change to the proper authority as
required by Minn. Stat. Section 259.13. (See Felon Name Change Instructions)
ii. Petitioner has attached to this Petition an Affidavit of Service of the Notice marked
Exhibit “A”.
39. Other
Include other facts you think the Court should know.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
BASED UPON THE ABOVE INFORMATION, Petitioner requests that the Court issue a
final judgment and decree granting the following relief:
1.
Dissolving the bonds of matrimony between Petitioner and Respondent to end the marriage.
2.
Legal Custody : Legal Custody means which parent(s) have a say in the major decisions regarding
the child(ren)’s life including education, religious upbringing and medical treatment.
Granting legal custody of each minor child of the parties as follows:
Name of Child
Granting Legal Custody:
Solely to Petitioner OR
Solely to Respondent OR
Jointly to
both parties.
Solely to Petitioner OR
Solely to Respondent OR
Jointly
to both parties.
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Solely to Petitioner OR
Solely to Respondent OR
Jointly
Solely to Respondent OR
Jointly
Solely to Respondent OR
Jointly
to both parties.
Solely to Petitioner OR
to both parties.
Solely to Petitioner OR
to both parties.
3.
Physical Custody: Physical custody identifies which parent(s) will handle the routine daily care and
control of the child(ren).
Granting physical custody of each of the minor children of the parties as follows:
Name of Child
Granting Physical Custody:
Solely to Petitioner OR
Solely to Respondent OR
Jointly to
both parties.
Solely to Petitioner OR
Solely to Respondent OR
Jointly
Solely to Respondent OR
Jointly
Solely to Respondent OR
Jointly
Solely to Respondent OR
Jointly
to both parties.
Solely to Petitioner OR
to both parties.
Solely to Petitioner OR
to both parties.
Solely to Petitioner OR
to both parties.
4.
Parenting Time
a. Petitioner's parenting time shall be:
Unsupervised
Supervised
Reserved
b. Respondent's parenting time shall be:
Unsupervised
Supervised
Reserved
c. Parenting Time Schedule shall be as follows:
(Clearly explain the time each parent will spend with each child. Include the time (o'clock) when
the child will transfer from one parent to the other. If you want the order to say who will pick up
and drop off the child, include that under "Other.")
Regular schedule:
Monday through Friday:
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Weekends:
Summer (if you want a different schedule in summer)
Telephone contact with the child(ren):
Unlimited or
Only at certain times as follows:
(describe the days and times when the parent and child(ren) may have telephone contact)
Exceptions to the Regular Schedule:
You can have a different schedule for holidays, school release days, and birthdays. If you do not
want a different schedule, leave it blank.
School Release days or breaks during the school year
Any school release day schedule will supercede the regular parenting schedule.
Birthdays (child's birthday, parent's birthday)
Holidays
Any holiday or birthday schedule will supercede the regular and school release parenting schedule.
Other
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d. Under the above Schedule:
The children are with Petitioner:
less than 10% of the time
10-45% of the time
45.1-50% of the time
more than 50% of the time
5.
The children are with Respondent:
less than 10% of the time
10-45% of the time
45.1-50% of the time
more than 50% of the time
Child Support
Ordering the payment of child support based on each parent's income. If either parent fails to
provide income information, the court will set child support based on the available evidence
and Minnesota law.
6.
Health Care Coverage for the Joint Children
Choose a, b, or c.
a.
Petitioner
Respondent shall provide medical insurance for the joint minor child(ren):
through his/her employer or union OR
by obtaining and paying for private insurance.
Petitioner
Respondent shall provide dental insurance for the joint minor child(ren):
through his/her employer or union OR
by obtaining and paying for private insurance.
The other parent must contribute to the costs of health coverage as required by law.
OR
b. If Medical Assistance or Minnesota Care is open for the child(ren), ordering
the non-custodial parent to make a sum certain payment as reimbursement through
income withholding through the Minnesota Child Support Payment Center.
OR
c. Reserving the issue of medical and dental insurance for the minor children.
d. Other:
____________________________________________________________
________________________________________________________________________
________________________________________________________________________.
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7.
Unreimbursed Medical and Dental Costs for the Children
"Unreimbursed medical and dental costs" are expenses not covered by insurance, not paid by medical
assistance, and not paid by the State of Minnesota. Examples include deductibles, co-pays, and procedures
not covered by insurance or assistance. Choose a. or b.
a. Ordering each parent to pay a share of the unreimbursed medical and dental costs for the
child(ren) of the parties, based on the relative incomes of the parties; OR
b. Reserving the issue of unreimbursed medical and dental costs.
8.
Medical and Dental Insurance for the Parties
a. Ordering each party to provide for his or her own
medical
dental insurance.
b. Ordering ____________________________(full name) to provide
medical
dental
insurance for ______________________________________________ (full name).
c. Allowing____________________________(full name), at his/her own expense, to
continue the dependent coverage available under the other party’s insurance plan, pursuant
to federal and state statutes.
d. Reserving the issue of medical and dental insurance for the parties.
9.
Child Care Expenses
a. Ordering Petitioner and Respondent to each pay a share of the monthly child care
expenses, according to Minnesota law; OR
b. Reserving the issue of child care expenses.
10.
Spousal Maintenance
a. Maintenance is denied to Petitioner and Respondent.
b. Reserving the issue of maintenance.
c. Ordering
11.
Petitioner
Respondent to pay spousal maintenance to
Petitioner
Respondent.
Vehicles
Awarding the vehicles as follows and ordering the party receiving the vehicles to pay for any loans
or insurance for such vehicle:
Year / Make / Model
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12.
Marital Property
Dividing the parties’ marital property, household goods, furniture and furnishings either:
a. As currently divided OR
b. As follows (attach additional page if necessary):
To Petitioner:
To Respondent:
13.
Non-Marital Property
Dividing the parties non-marital property
a. As currently divided OR
b. As follows (attach additional page if necessary):
To Petitioner:
To Respondent:
14.
Cash and Accounts
a. Awarding the savings, and investments as follows:
Institution
Type of Account
Account #
Amount
Awarded to
(Last 4 digits only)
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$
XX
$
XX
$
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b.
XX
$
XX
$
XX
$
Awarding any cash not included in a. above to the party who currently has the cash OR
Awarding the cash as follows:
15.
Business
None OR
Awarding the parties’ business as follows: _________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
16.
Manufactured Home
None OR
Awarding the manufactured home located at :
street address
city
to
state
Petitioner
Respondent. The debt on the manufactured home owed to:
shall be paid by
Petitioner
17.
Respondent.
Real Property
None OR
Awarding solely to
Petitioner
Respondent all right, title, and interest of husband
and wife in the real property located at:
Street address___________________________________________________________________
in the City of
, County of ___________________________,
State of
, which has the following legal description: ______________
_______________________________________________________________________________
_______________________________________________________________________________
with the following mortgages and loans to be paid, after the divorce is final, by
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Respondent:
1st Mortgage: Amount currently owed: $
and name of lender:
2nd Mortgage: Amount currently owed: $
and name of lender:
and subject to the following liens or other agreements:
A lien in favor of
Petitioner
Respondent in the amount of $
.
Other request regarding the property: (describe the request fully)
18.
Additional Real Property
None OR
Awarding solely to
Petitioner
Respondent all right, title, and interest of husband and
wife in the real property located at:
Street address___________________________________________________________________
in the City of
, County of ___________________________,
State of
, which has the following legal description: ______________
_______________________________________________________________________________
_______________________________________________________________________________
with the following mortgages and loans to be paid, after the divorce is final, by
Petitioner
Respondent:
1st Mortgage: Amount currently owed: $
and name of lender:
2nd Mortgage: Amount currently owed: $
and name of lender:
and subject to the following liens or other agreements:
A lien in favor of
Petitioner
Respondent in the amount of $
.
Other request regarding the property: (describe the request fully)
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19.
Retirement Funds
a. Awarding Petitioner’s pension, profit sharing, retirement plan, I.R.A., or 401(k) or other
retirement fund as follows:
100% to Petitioner
OR
Dividing Petitioner's retirement benefits fairly and equitably between the parties.
b. Awarding Respondent’s pension, profit sharing, retirement plan, I.R.A.or 401(k) or other
retirement fund as follows:
100% to Respondent OR
Dividing Respondent's retirement benefits fairly and equitably between the parties.
20.
Debts
a. Dividing the debts as follows and ordering each party to hold the other harmless from any
responsibility for the debts so divided. Include all debts listed at 37 above.
Debt Owed To:
To Be Paid By:
b. Ordering that each party is solely responsible for paying any other debts incurred solely by
him or her and ordering each party to hold the other harmless from any responsibility for
such separately incurred debts.
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21.
Name Change
Petitioner is not requesting a name change; OR
Changing Petitioner’s name to:
First
Middle
22.
Other
23.
Ordering such other relief as the Court deems just and equitable.
24.
READ and SIGN the Verification and Acknowledgments.
Last
STATE OF MINNESOTA
)
) SS
COUNTY OF
)
(County where Petition is signed)
Verification and Acknowledgments
a.
I have read this document. To the best of my knowledge, information and belief the information
contained in this document is well grounded in fact and is warranted by existing law.
b.
I have not been determined by any Court in Minnesota or in any other State to be a frivolous
litigant and I am not the subject of an Order precluding me from serving or filing this document.
c.
I am not serving or filing this document for any improper purpose, such as to harass the other
party or to cause delay or needless increase in the cost of litigation or to commit a fraud on the
Court.
d.
I understand that if I am not telling the truth or if I am misleading the Court or if I am serving or
filing this document for an improper purpose, the Court can order me to pay money to the other
party, including the reasonable expenses incurred by the other party because of the serving or
filing this document, Court costs, and reasonable attorney’s fees. I understand that I could also be
prosecuted for perjury if I am not telling the truth in my Petition.
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DATE:
/
Month
/
Day
Petitioner’s Signature
(Sign only in presence of notary public)
Year
Mailing Address (Street):
City, State
Zip Code:
Telephone: (
)
Subscribed and sworn to before me this
______day of _____________, ______.
_______________________________
Notary Public or Court Clerk
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