Free State of Minnesota - Minnesota

State of Minnesota
County of Judicial District:
Court File Number: Assigned Judge: Case Type:

District Court

Dissolution without Children

In Re the Marriage of:
Name of Petitioner (first, middle, last) and Name of Respondent (first, middle, last) STATE OF MINNESOTA ) COUNTY OF )SS (County where Petition is signed)

Petition For Dissolution Of Marriage Without Children

1.

Information about Petitioner Full Name: _______________________________________________________________________
First Middle Street Address Last Apt. No. _______ City County State Zip Code

Address where you live:

Mailing address:

Same as above address OR

Street Address

Apt. No. _______

City

County

State

Zip Code

Date of Birth: ________________________
Month Day Year

Petitioner is the

husband

wife.

List all of Petitioner's former or other names or write "None":

First

Middle

Last

First

Middle

Last

2.

Information about Respondent Full Name:
First Middle Last

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Address where Respondent lives:
Street Address Apt. No.

City

County

State

Zip Code

Mailing address:

Same as above address OR

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":
First Middle Last

First

Middle

Last

3.

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? Has Respondent been living in Minnesota for the past six (6) months? YES NO UNKNOWN YES NO

5.

Armed Forces Is Petitioner an active duty member of the armed forces? YES NO YES NO

If YES, has Petitioner been stationed in Minnesota for the past six (6) months?

Is Respondent an active duty member of the armed forces?
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YES

NO

UNKNOWN
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If YES, has Respondent been stationed in Minnesota for the past (6) months?

YES

NO

6.

Marriage Cannot be Saved There has been an irretrievable breakdown of my marriage relationship with Respondent and the marriage cannot be saved.

7.

Physical Living Situation Do Petitioner and Respondent live together at this time? If NO, the date we separated was:
Month Day Year

YES

NO .

If YES, Petitioner and Respondent are living together because:

8.

Other Proceedings a. Has a separate court case for marriage dissolution, legal separation, or annulment already been started by Petitioner or Respondent in Minnesota or elsewhere? type of court case is: YES NO If YES, the

, 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

9.

Protection or Harassment Order Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and Respondent? YES NO If YES: The Order protects: County in . Petitioner Respondent State on

and the Order was filed in date, and the Court file number is A copy of the Order must be attached.

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10.

Children
"Minor" children are under age 18, or under age 20 but still in high school.

a. Do Petitioner and Respondent have minor children together?

YES

NO

b. Do Petitioner and Respondent have any adult dependent children who are not able to support themselves because of a physical or mental condition? YES NO (If you answered YES,

you may ask the court to make an order regarding support for the adult dependent, but you should use the Marriage Dissolution With Children forms to do this.) c. Has Wife given birth, since marrying Husband, to a child who is not Husband's child? YES NO

If you answered NO to c, skip to d. If YES continue below: i. Fill in the information for all children born to Wife since marrying Husband, who are not husband's biological children. Full Name of Child Date of Birth Age

ii. Is there a court order naming someone other than the Husband as the father of the child(ren) listed in (i)? YES NO If YES, fill in: Date of Court Order County/State of Order Court Case No.

Full Name of Child

iii. Have the Wife and biological Father signed a Minnesota Recognition of Parentage (ROP) for any of the children listed in (i) above? YES NO

If YES, state the full name of the child: and attach to the Petition a certified copy of the Recognition of Parentage.
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Has the Husband signed the "Husband's Non-Paternity Statement" for any of the children listed at (i) above? YES NO

If YES, state the name of the child: and attach a certified copy of the "Husband's Non-Paternity Statement."

Stop: For each minor child listed at c.(i.) you must have a court order OR the Recognition of Parentage and Non-Paternity Statement to use the Dissolution Without Children forms. Marriage Dissolution with Children forms. Otherwise, use the

d. Is Wife pregnant?

YES

NO

UNKNOWN (If the Wife is pregnant you are using

the wrong form. Use Marriage Dissolution with Children.) 11. Public Assistance / Medical Assistance
Note: 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. Petitioner receives public assistance from the State of Minnesota:

YES

NO

If YES, the assistance is from __________________ County. (Check all that apply): MFIP Tribal TANF General Assistance Child Care Assistance

Minnesota Care

Medical Assistance

b. Respondent receives public assistance from the State of Minnesota: YES NO UNKNOWN

If YES, the assistance is from __________________ County. (Check all that apply): MFIP Tribal TANF General Assistance Child Care Assistance

Minnesota Care

Medical Assistance

12.

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. Petitioner receives Supplemental Security Income (SSI): $ per month.

NO

YES in the amount of

b. Respondent receives Supplemental Security Income (SSI): $
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NO

YES in the amount of

per month, or
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UNKNOWN
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13.

Petitioner's Employment a. Is Petitioner employed? YES NO Is Petitioner Self-Employed? YES NO

b. Name and address of Petitioner's employer. (If Petitioner has more than one job, list the Name and Address of each employer.) ____________________________________________________________________________
Name of Petitioner's Employer (If Self-Employed, list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

Name of Petitioner's Employer (If Self-Employed, list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

14.

Petitioner's Gross Income
The Income questions ask for monthly income. If you are paid weekly, multiply your weekly income by 4.33 to get monthly income. If you are paid every two weeks, multiply by 2.17 to get monthly income. If you are paid twice a month, multiply by 2.

Sources of Income Self Employment Income

Amount per month (or zero) before taxes and deductions $ per month

If you are self employed, calculate your net monthly revenues as follows: (Annual gross revenues minus annual ordinary and necessary business expenses) divided by 12 = Net Monthly Revenue. Also, attach Schedule C from last year's tax return to this Petition.

Income from all jobs Commissions from all jobs Unemployment benefits Social Security Retirement, Survivors or Disability Income (SSDI or RSDI) Investments or Rental Income Annuity payments Pension or Disability from work or military
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$ $ $

per month per month per month

$ $ $ $

per month per month per month per month
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Workers Compensation Court-ordered spousal maintenance you receive Other ____________________
Identify Source

$ $ $ $

per month per month per month per month

Total gross income

Does Petitioner receive child support payments?

YES

NO

If YES, Petitioner

receives child support payments from ____________________________(name(s) of payor(s)) in the total amount of $_________________per month. 15. Respondent's Employment Is Respondent employed? YES NO YES NO UNKNOWN UNKNOWN

Is Respondent Self-Employed?

Name and address of Respondent's employer. (If Respondent has more than one job, list the Name and Address of each employer.) ____________________________________________________________________________
Name of Respondent's Employer (If Self-Employed list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

___________________________________________________________________________
Name of Respondent's Employer (If Self-Employed list name and business address)

____________________________________________________________________________
Employer's Street Address

City

State

Zip Code

16.

Respondent's Gross Income 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 per year, with week
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bonuses, overtime or commissions in the additional amount of $
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month

year. This is Respondent's

Net Income (after taxes and deductions) or

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.)
The Income questions ask for monthly income. If Respondent is paid weekly, multiply weekly income by 4.33 to get monthly income. If Respondent is paid every two weeks, multiply by 2.17 to get monthly income. If Respondent is paid twice a month, multiply by 2.

Sources of Income Self Employment Income

Amount per month (or zero) before taxes and deductions $ per month

If Respondent is self employed, calculate net monthly revenues as follows: (Annual gross revenues minus annual ordinary and necessary business expenses) divided by 12 = Net Monthly Revenue. Also, attach Schedule C from last year's tax return to this Petition, if available.

Income from all jobs Commissions from all jobs Unemployment benefits Social Security Retirement, Survivors or Disability Income (SSDI or RSDI) Annuity payments Investments or Rental Income Pension or Disability from work or military Workers Compensation Court-ordered spousal maintenance you receive Other ____________________
Identify Source

$ $ $

per month per month per month

$ $ $ $ $ $ $ $

per month per month per month per month per month per month per month per month

Total gross income

17.

Medical / Dental Insurance a. Does Petitioner have insurance coverage through his/her employment? Medical: YES NO Dental: Petitioner YES NO

If YES, this medical insurance covers: and this dental insurance covers: b.

Respondent

Petitioner

Respondent

Does Respondent have insurance coverage through his/her employment?

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Medical: Dental:

YES YES

NO NO

UNKNOWN UNKNOWN Petitioner Respondent Respondent

If YES, this medical insurance covers: and this dental insurance covers: c.

Petitioner

Does Petitioner receive Medical Assistance or Minnesota Care through the State of Minnesota? YES NO

d. Does Respondent receive Medical Assistance or Minnesota Care through the State of Minnesota? 18. Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.

YES

NO

UNKNOWN

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 following education:_____________________________________________. Respondent's gross monthly income totals $______________. Respondent's monthly expenses total
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$________________, 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. .

19. 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? Does Respondent own a vehicle?

YES YES

NO NO UNKNOWN

List all vehicles owned by husband or wife together or separately: Type of Vehicle (car, boat, truck etc.) Year/Make/ Model Name(s) on Title $ $ $ $ 20. $ $ $ $ $ $ $ $ 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 between the Petitioner and Respondent to Petitioner's satisfaction? YES NO

If NO, Petitioner requests the following marital property:

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________.

21.

Non-Marital Property
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DIV402

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 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? If YES, list Petitioner's non-marital property: YES NO

. b. Does Respondent have non-marital property? If YES, list Respondent's non-marital property: YES NO UNKNOWN

___________________________________________________________________________.

22.

Cash & Accounts ­ Not including Pension and Employer-Funded Retirement Accounts Does Petitioner have money in banks, savings, cash or investments? Does Respondent have money in banks, savings, cash or investments? 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 #26. Financial Institution Type of Account Account #
Last 4 digits only

YES
YES

NO
NO UNKNOWN

Amount

Belongs to:
(name on account)

XX XX
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$ $
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XX XX XX XX b. List cash not listed at a.: Petitioner has cash in the amount of $ Respondent has cash in the amount of $

$ $ $ $

. OR UNKNOWN.

23.

Business Interest Does Petitioner have an interest in a business? Does Respondent have an interest in a business? YES YES NO NO UNKNOWN

If YES, the name of the business is ____________________________, the address is ________________________________________________________________________________ and the value is $________________. How did you arrive at this value?

24.

Manufactured Home Does Petitioner own a manufactured home? Does Respondent own a manufactured home? YES YES NO 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?

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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 25.

25. 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. b.

Do Petitioner and Respondent jointly own real property?

YES

NO

Does Petitioner own real property solely in his/her own name or with someone other than Respondent? YES NO

b.

Does Respondent own real property solely in his/her own name or with someone other than Petitioner? YES NO UNKNOWN None One Two

c.

How many properties are owned by you and your spouse in total? Three _______

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).

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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 $ 2nd Mortgage: Amount currently owed $ and name of lender

and name of lender

Other mortgages or loans:

6. Current Market Value of this property: How did you arrive at this value?

$___________________________________

7. This property is the homestead: _______Yes 26. Retirement Plans

_________No

Does Petitioner have a retirement account? (IRA, 401(k), 403(b) or other) YES
DIV402 State

NO If YES:
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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:

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: Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other) YES 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: 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 NO UNKNOWN

If YES, and it is a Pension, Profit-Sharing, or other Retirement Plan: a) The name of the plan is: b) The employer, union or group providing the plan is:

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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: ___________________________________

27.

Debts Does Petitioner have debt? Does Respondent have debt? YES YES NO 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 $ $ $ $ $ $ $ $ Balance Owed Monthly Payment

$ $ $ $ $ $ $ $

Total Debt 28. Name Change Does Petitioner want to change his/her name? a. Petitioner's name should be changed to: YES NO

$

$

If YES, answer (a) through (c):

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First

Middle

Last

Is this name a former legal name or maiden Name? Petitioner wants to change to this name is:

YES

NO If NO, the reason

b.

Petitioner has no intent to defraud or mislead anyone by changing his/her name: TRUE FALSE YES NO If YES, answer i. and ii:

c.

Has Petitioner been convicted of a felony?

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".

29. 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.

Medical and Dental Insurance for the Parties a. Ordering each party to provide for his or her own medical dental insurance. medical dental

b. Ordering ____________________________(full name) to provide

insurance for ______________________________________________ (full name).

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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. 3. Spousal Maintenance a. Maintenance is denied to Petitioner and Respondent. b. Reserving the issue of maintenance. c. Ordering Petitioner 4. 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 Awarded to: Petitioner Respondent to pay spousal maintenance to

Respondent.

5.

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:

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To Respondent:

6.

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:

7.

Cash and Accounts a. Awarding the savings and investments as follows: Institution Type of Account Account #
(Last 4 digits only)

Amount $ $ $ $ $ $

Awarded to

XX XX XX XX XX XX

b.

Awarding any cash not included in a. above to the party who currently has the cash OR Awarding the cash as follows:

8.

Business None OR

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Awarding the parties' business as follows:__________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

9.

Manufactured Home None OR Awarding the manufactured home located at :
street address city state

to

Petitioner

Respondent. The debt on the manufactured home owed to: shall be paid by

Petitioner

Respondent.

10.

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 State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Respondent: 1st Mortgage: Amount currently owed: $ and name of lender: Petitioner

2nd Mortgage: Amount currently owed: $

and name of lender:

and subject to the following liens or other agreements:
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A lien in favor of

Petitioner

Respondent in the amount of $

.

Other request regarding the property: (describe the request fully)

11.

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 State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Respondent: 1st Mortgage: Amount currently owed: $ and name of lender: Petitioner

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 $ .

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Other request regarding the property: (describe the request fully)

12.

Retirement Funds a. Awarding Petitioner's pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: Petitioner has no retirement funds OR 100% to Petitioner OR

Dividing Petitioner's retirement benefits fairly and equitably between the parties as follows

. b. Awarding Respondent's pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: Respondent has no retirement funds OR 100% to Respondent OR

Dividing Respondent's retirement benefits fairly and equitably between the parties as follows

.

13.

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 #27 above.

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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.

14.

Name Change Petitioner is not requesting a name change; OR Changing Petitioner's name to:
First Middle Last

15.

Other:

16. 17.

Ordering such other relief as the Court deems just and equitable. Read and sign the Verification and Acknowledgments.

STATE OF MINNESOTA

)

) SS COUNTY OF ) (County where Petition is signed)
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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. 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. 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. 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.

b.

c.

d.

DATE: Month

/ Day

/ Year Petitioner's Signature (Sign only in presence of notary public)

Subscribed and sworn to before me this _________day of ______________, 20________. _____________________________ Notary Public or Court Clerk

Street Address: City, State: Zip Code: Telephone: ( ) ______

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