State of Minnesota
County Judicial District: Court File Number: Case Type:
In Re the Custody of:
Petition To Establish Custody And Parenting Time
[Minn. Stat. § 518.156] Born (mo/day/yr) Recognition of Parentage signed [Minn. Stat. § 257.75, subd. 3] Petitioner and
Respondent 1. I am the father / mother (circle one). Full Name
First Middle Last Street Address Apt. #
2. Respondent is the father / mother (circle one). The Respondent's name and address is: Full name
First Street Address Middle Last Apt. #
3. The name(s) and date(s) of birth of the minor child(ren) involved in this action are: Child's Full Name Date of Birth
First Middle Last Month / Day / Year
Month / Day / Year
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4. The child(ren) currently live(s) with: Me Other parent (print full name): __________________________________________________. The address of the child(ren) is/are: ___________________________________ in the City of _________________________, County of ____________________________, State of _______________________, zip code ________________. The child(ren) has / have lived at this address since
_______________________ (mo/day/yr). If child(ren) has / have lived less than six months at the above listed address, list dates and locations of where the child(ren) has / have been living for the last six months: ______________________________________________________________________________ ______________________________________________________________________________ 5. Petitioner and Respondent signed a Minnesota Recognition of Parentage for the minor
child(ren) listed above. The Recognition of Parentage has been filed with Vital Statistics and is a basis for bringing an action to grant custody, parenting time, and/or child support pursuant to Minn. Stat. § 257.75, subd. 3 (2007). (check one)
Petitioner has attached a certified copy of the Recognition of Parentage to this Petition. Petitioner requested a certified copy from the Minnesota Department of Heath, Bureau of
Vital Statistics and will file it with the court when Petitioner receives it. 6. A court appointed guardian or custodian has been appointed for the child(ren).
No Yes A guardian or custodian has been appointed for the child(ren) by court order in court
file no. ________________________ in the State of ___________________________ and the name of the guardian / custodian is _________________________________________________ (Note: Minn. Stat. § 518.156, subd. 2 requires the Petitioner to give written notice of this proceeding to the guardian / custodian.) 7. Petitioner's request for custody and parenting time: a. Legal Custody: Legal custody means having a right to participate in the major decisions regarding the child's life, including education, religious upbringing and medical treatment. It is in the child's best interests that legal custody is granted as follows: (check one)
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Joint legal custody to both parents Sole legal custody to Mother Father
b. Physical Custody: Physical custody identifies who will handle the routine daily care and control of the child, and who the child will live with. It is in the child's best interests that physical custody is granted as follows: (check one)
Joint physical custody to both parents Sole physical custody to Mother Father
8. A juvenile court proceeding or child protection case involving the child(ren) in this case is open: YES NO If YES, this case is in _______________________ County in the State of _________________, and the court file number is _________________________. The child protection worker's name is .
9. An Order for Protection involving me and the other parent __________________________ (print full name) ___________________________________and/or the child(ren) is open:
If YES, this case is in _______________________________ County in the State of ____________________________, and the court file number is ________________________. A copy of the Order for Protection is attached. 10. Parenting Time: It is in the child's best interests that parenting time be granted as follows:
grant parenting time to the Mother Father grant supervised parenting time to the Mother Father deny parenting time to the Mother Father
11. Child Support: (check one box)
There is no existing child support order and Petitioner is asking the court to establish child
support in accordance with child support guidelines.
CHC103 State ENG Rev 01/09 www.mncourts.gov/forms Page 3 of 4
There is no existing child support order and child support is not being requested in this
There is an existing child support order for the child(ren) named in this action, located in the
County of _________________________ , State of ____________________________, court file number ____________________________________.
The Petitioner requests that the Court grant the following relief:
1. I am asking the court to grant legal custody as follows: (pick one box)
joint legal custody to both parents sole legal custody to the Mother Father
2. I am asking the court to grant physical custody as follows: (pick one box)
joint physical custody to both parents sole physical custody to the Mother Father
3. I am asking the court to: (pick one)
grant parenting time grant supervised parenting time to the Mother Father deny parenting time to the Mother Father
4. Optional only check box if asking the court for child support.
I am asking the court to establish child support according to the child support guidelines.
Child support includes basic support, medical support, and child care support. 5. Granting such other and further relief as the court may deem just and equitable.
DATE: Signature Street Address City/State/Zip Code ( ) Telephone Number
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