Free STATE OF MINNESOTA - Minnesota

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

District Court

In Re the Custody of:

Born (mo/day/yr)

Affidavit in Support of Motion To Establish Custody And Parenting Time

Born (mo/day/yr)

Petitioner and Respondent STATE OF MINNESOTA ) COUNTY OF _______________________ )SS My name is and I state under oath that:

1. I am the Petitioner in this case, and I make this Affidavit in support of my petition asking the court to decide custody and parenting time. Optional: (check only if requesting)

Petitioner is requesting the court to establish child support
2. I want the Court to grant legal custody of the child(ren) (check one):

a. Jointly to both parents b. Solely to (check one): Me Other party (print full name):
3. I want the Court to grant physical custody of the child(ren) (check one):

a. Jointly to both parents b. Solely to (check one): Me Other parent (print full name):

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4. I understand that the Judge must decide custody based on what is best for my child(ren), and that by filling in (a) through (o) of this paragraph 4, that I am giving the Judge information needed to make that decision. a. Describe the custody arrangement you want:

Describe the custody arrangement the other parent wants:

b. Describe the custody arrangement the child(ren) want(s) (if the child(ren) is / are old enough to decide):

c. Describe what you do each and every day to take care of your child(ren) (be very detailed):

In contrast, the other parent does the following each day to take care of the child(ren):

d. Describe the closeness of the relationship of each parent and child:

e. Describe the interaction of the child(ren) with each parent, brother, sister, and anyone else who is important to the child(ren) and how that will change if your request is granted:

f. Describe the child(ren)'s adjustment to home, school, and community:

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g. Describe the length of time the child(ren) has / have lived in a stable satisfactory place and the need to stay in that place:

h. Describe the permanence, as a family unit, of the existing or proposed custodial home:

i. Describe the mental and physical health of all individuals involved:

j. Describe the ability of each parent to give the child(ren) love, affection and guidance and continue educating and to raise the child(ren) in the child(ren)'s culture, religion or creed, if any:

k. Describe the child(ren)'s unique cultural needs and what role you play in meeting the cultural needs; then describe the role the other parent plays:

l. There

is is not domestic abuse in my household.

The following people are involved in

the domestic abuse (tell how the people are related to the child(ren) and / or to you):

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The domestic abuse in my household affects the child(ren) in the following way:

m. There

is is not domestic abuse in the other parent's household.

The following people are

involved in the domestic abuse (tell how the people are related to the child(ren) and / or to the other parent):

The domestic abuse in the other parent's household affects the child(ren) in the following way:

n. Describe what you will do to encourage and permit frequent and continuing contact by the other parent with the child(ren) (except when there is domestic abuse):

o. Describe what the other parent does to encourage or discourage your contact with the child(ren):

5. I want the court to:

order the parenting time schedule as stated in my Motion order supervised parenting time for the other parent deny parenting time to the other parent

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6. I believe that this schedule ordering supervised parenting time denying parenting time is in the best interest(s) of the child(ren) because

If parenting time is supervised, parenting time should be supervised by:

Note: You and/or the other parent may have to pay a fee for each supervised visit. 7. I want the Court to order that the child(ren) be transferred at a parenting time exchange center if one is located in the area, and for both parents to follow all rules of the parenting time exchange center:

YES NO.

If YES, this is necessary because

If NO, the child(ren) should be transferred at: because

8.

Information about child support. Continue only if asking to establish child support (child support includes basic support, medical support, and child care support). If not, go to the last page for notary and signature.

Current Information About Me I am currently (check all that apply): Married Separated Divorced 9.

Living with a companion

Single

I am currently (check one) employed unemployed (if employed, answer the following):

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a. b. c. d. e. f. g. h. i.

Employer: Address: Work telephone number: Occupation /Type of work: Length of employment: Supervisor: Gross Pay: $_________________ This does does not include overtime pay. Paid: Weekly Every other week Twice a month Monthly Previously employed by for ___________ years prior to the above employment. Pension Payments $ Unemployment Benefits $ Workers' Compensation $ Disability Payments $ Other $ MinnesotaCare

10. I have the following additional sources of income: Commissions $ Annuity Payments $ Military / Naval Retirement $ Spousal Maintenance Received $ Self-Employment $

11. I receive (check only if it applies) MFIP Medical Assistance General Assistance SSI Child Care Assistance

12. The child(ren) currently receives monthly social security or veteran's benefits in the amount of $ based on my disability the other parent's disability and is paid to me other parent. 13. I am court ordered to pay monthly spousal maintenance. (check one) YES NO If yes, how much? 14. I support the following nonjoint child(ren): Child's Name Date of Birth

Court ordered Living in child support my home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No (If ordered to pay child support for any child listed above, provide copies of court orders)

Relationship

15. There are number of people who live in my household and my monthly expenses at the present time are as follows (include the total monthly household expenses): Monthly Payment at Present Time a. b. c. d. House payment or Rent Real Estate Taxes, if not included in (a) Association Dues or Lot Rent (for property) Insurance: Homeowners, if not included in (a) Car Life $ $ $ $ $ $

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e.

f. g. h. i. j. k. l. m. n.

o. p. q. r. s.

Utilities: (Average Monthly Amount) Gas Electricity Telephone Water and garbage Cable TV Food Clothing Laundry/dry cleaning Personal allowances and incidentals Magazine and newspapers Uninsured / unreimbursed medical expenses Uninsured / unreimbursed dental expenses Child care expenses Transportation expenses: Car payment License Gasoline Repairs Recreation/Entertainment Child(ren)'s needs (sports/school/hobbies) Allowances Other (list) Charge accounts and loans (list): Name of Account 1. 2. 3. 4. 5. TOTAL MONTHLY EXPENSES:

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Balance Owed $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $

16. The following people help me pay my current monthly expenses listed in question 15: Spouse Companion Roommate(s) Relatives No One 17. The value of the property I currently own by myself or with someone else is: Home $____________________ Household goods $____________________ Purchase price of my home $_________________ Balanced owed on my home $____________________ Other real estate $____________________ Checking/savings $____________________ Automobiles $____________________ (year and make) Recreational vehicles $____________________ (year and make) Personal property $____________________ Stocks/bonds/etc. $____________________

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Current Information About Other Parent 18. To the best of my knowledge, the other parent is currently: (check one) employed unemployed (if employed, answer the following): a. Employer: b. Address: c. Work telephone number: d. Occupation / Type of work: e. Length of employment: f. Supervisor: g. Gross Pay: $_________________ This does does not include overtime pay h. Paid: Weekly Every other week Twice a month Monthly Unknown i. Previously employed by for ___________ years prior to the above employment 19. To the best of my knowledge, the other parent has the following additional sources of income: Commissions $ Pension Payments $ Annuity Payments $ Unemployment Benefits $ Military / Naval Retirement $ Workers' Compensation $ Spousal Maintenance Received $ Disability Payments $ Self-Employment $ Other $ 20. To the best of my knowledge, the other parent receives (check only if it applies) MFIP Medical Assistance MinnesotaCare General Assistance SSI Child Care Assistance 21. To the best of my knowledge, the other parent is ordered to pay spousal maintenance. (check one) YES NO If yes, how much? 22. To the best of my knowledge, the other parent supports the following nonjoint child(ren): Child's Name Date of Birth Relationship Court ordered Living in child support the home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No Parents Health Care Coverage Information 23. About me: (check all that apply) I have health care coverage available for the joint child(ren) I do not have health care coverage available for the joint child(ren) I cannot afford to pay my proportionate share of health care coverage for the joint child(ren) I have public coverage for myself in the form of Medical Assistance MinnesotaCare I am court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children I have health care coverage and/or dental insurance coverage in place for the following people: Cost of monthly health care coverage for self: $ Cost of monthly health care coverage for family coverage: $ Cost of monthly dental insurance for self (if separate coverage from health care coverage):

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$ Cost of monthly dental insurance for family coverage (if separate coverage from health care coverage): $ 24. Currently, there is: no court order that directs either parent to carry health care coverage for the joint child(ren). Medical Assistance in place for the joint child(ren) MinnesotaCare in place for the joint child(ren). 25. About the other parent: (check all that apply) I do not know if the other parent has health care coverage available or in place for the joint child(ren) The other parent has health care coverage available for the joint child(ren) The other parent does not have health care coverage available for the joint child(ren) The other parent is court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children. The other parent has health care coverage and/or dental insurance coverage in place for the following people: Cost of monthly health care coverage for self: $ Cost of monthly health care coverage for family coverage: $ Cost of monthly dental insurance for self (if separate coverage from health care coverage): $ Cost of monthly dental insurance for dependents (if separate coverage from health care coverage): $ Cost of health care coverage is unknown Child Care Obligation 26. There is no court ordered child care obligation and I have child care expenses for the joint child(ren). The current total monthly costs of child care for the joint child(ren) is / are $ (If a child care subsidy is being received, list the total monthly cost, not just the portion paid by the parent) I have no child care expenses for the joint child(ren). 27. The following is additional information regarding the reasons I am asking the Court to establish custody, parenting time, and/or child support:

Dated:
Signature (Sign only in front of notary public or court administrator)

Name: Subscribed and sworn to before me this day of , Address: City/State/Zip: Telephone: (
Notary Public \ Deputy Court Administrator

)

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