Free STATE OF MINNESOTA - Minnesota

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Judicial District: Court File Number: Case Type: Family

In Re the Custody of:

Born (mo/day/yr)

Affidavit in Support of Responsive Motion to Establish Custody And Parenting Time

(Petitioner/Plaintiff) vs.

(Respondent/Defendant)

) ) SS COUNTY OF _______________________ )
(County where Affidavit signed)

STATE OF MINNESOTA

My name is

and I state under oath that:

1. I am the Respondent in this case, and I make this Affidavit in support of my responsive motion for custody and parenting time (visitation). 2. A juvenile court proceeding or child protection case involving any or all of the children in this case is open: YES NO. County in the State of , and the case file number is The child protection worker's name is 3. An Order for Protection involving me and: Petitioner Respondent (print full name) YES NO. . .

If YES, this case is in

and/or the child(ren) exists: If YES, this case is in , and the case file number is A copy of the Order for Protection is attached.

County in the State of .

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4. The children currently live with: Me Petitioner Respondent (print full name): I am the child(ren)'s: (list relationship) The other party is the child(ren)'s:(list relationship) The address of the child(ren) is/are: in the City of , State of , Zip Code . . . . .

The child(ren) have lived at this address since: (mo/day/yr) 5. I want the Court to grant legal custody of the child(ren) (check one): a. Jointly to both me and: because Petitioner Respondent

.

b. Solely to (check one): Me Petitioner Respondent (print full name): because

6. I want the Court to grant physical custody of the child(ren) (check one): a. Jointly to both me and: Petitioner Respondent with the child(ren) living with me at the following times:

and the child(ren) living with at the following times:

Petitioner

Respondent (Full name of other party)

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b. Solely to (check one): Me Petitioner Respondent (print full name):

7.

I believe that my request for physical custody is in the best interest(s) of the child(ren) because (list your reasons why, be specific)

8.

I want to respond to things the other party stated at paragraph 7 of his/her Affidavit. My response is:

9.

I want the parenting time schedule as stated in my Motion. I believe that this schedule is in the best interest(s) of the child(ren) because

10.

I want to respond to the other party's requests for parenting time. My response is:

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11.

I want the Court to order to order supervised parenting time:

YES

NO

If yes, I believe supervised parenting time is in the best interest(s) of the child(ren) because:

12.

The Petitioner has asked the Court to order supervised parenting time for me and the child(ren): YES Affidavit is: NO If yes, I object. My response to Petitioner's statements in paragraph 9 of his/her

13.

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 parties to follow all rules of the parenting time exchange center: YES NO. If YES, this is the best interest(s) of the child(ren) because

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

Note: The parenting time exchange center may require the parties to pay a fee for each exchange.

14.

Check all that apply: a. There is currently a court order requiring child support to b. in the amount of $ to pay per month.

I am asking the Court to decide or modify child support based on Minnesota child

support guidelines.

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c.

Other:

Current Information About Me 15. I am currently (check all that apply): Married Separated Divorced

Living with a companion

Single

16. I am 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 i. Previously employed by for ___________ years prior to the above employment. 17. I have the following additional sources of income: Commissions $ Annuity Payments $ Military / Naval Retirement $ Spousal Maintenance Received $ Self-Employment $ Pension Payments $ Unemployment Benefits $ Workers' Compensation $ Disability Payments $ Other $ MinnesotaCare General

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

19. The joint 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. 20. I am court ordered to pay monthly spousal maintenance. (check one) YES NO If yes, how much? 21. I support the following nonjoint child(ren): Child's Name Date of Birth

Child support Living in monthly amount 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

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22. My monthly expenses at the present time are as follows (if remarried, include total of 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 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 $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $0

e.

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

o. p. q. r. s.

23. The following people help me pay my current monthly expenses listed in question 15: Spouse Companion Roommate(s) Relatives No One 24. The value of the property I currently own by myself or with someone else is:

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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. $____________________ Current Information About Other Parent 25. 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. 26. 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 $ Other $ Self-Employment $ 27. To the best of my knowledge, the other parent receives (check only if it applies) Medical Assistance MinnesotaCare General Assistance SSI Child Care Assistance MFIP

28. To the best of my knowledge, the other parent is ordered to pay spousal maintenance. (check one) YES NO If yes, how much? 29. To the best of my knowledge, the other parent supports the following nonjoint child(ren): Child's Name Date of Birth Relationship Child support Living in monthly amount the home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No

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Parents Health Care Coverage Information Only answer if you are asking for a change in health care coverage and/or dental coverage for the joint child(ren). 30. About me: (check all that apply) I am court ordered to carry health care coverage for the joint child(ren) I now have private health care coverage available for the joint child(ren) I do not have or no longer have private 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) My proportionate share of health care coverage for the joint child(ren) should be changed I am court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children. I have private 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 dependents: $ 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): $ 31. Currently, there is: no court order that directs either parent to carry private health care coverage for the joint child(ren). a court order that directs me the other parent to carry private health care coverage for the joint child(ren). Medical Assistance MinnesotaCare currently in place for the joint child(ren). 32. About the other parent: (check all that apply) The other parent is court ordered to carry health care coverage for the joint child(ren) The other parent has private health care coverage available for the joint child(ren) The other parent does not have or no longer has private 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 private 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 dependents: $ 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): $ Child Care Obligation Only answer if you are asking for a change in child care support for the joint child(ren). 33. I am court ordered to pay a proportionate share of child care support and the amount of child care support has changed. There is no court ordered child care obligation and I have child care expenses.

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34. If there is an existing court order for monthly child care expenses, list the court ordered amount: $ 35. The current total monthly costs of child care are $ 36. The following is additional information regarding the reasons I am requesting to establish custody and parenting time:

Dated:
Signature (Sign only in front of notary public or deputy/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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