State of Minnesota
County
District Court
Judicial District: Court File Number: Case Type: Dissolution
Select County
In Re the Marriage of: Name of Petitioner vs.
Petitioner's Respondent's Prehearing Statement
Name of Respondent
1.
Personal Information a. b. Full Name Present Mailing Address Husband ________________________ ________________________ ________________________ c. d. Employer Name Employer Street Address City, State, Zip e. f. g. h. i. Birthdate Marriage Date ________________________ ________________________ ________________________ ________________________ ________________________ Wife _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________
Separation Date (Different Residences)___________________________________________ Date(s) of Temporary Order(s) (if any) ___________________________________________ Minor child(ren) of this marriage or who will be affected by this legal action are: Full Name of Child Date of Birth Age Living With
DIV105
State
ENG
Rev 5/08-D
www.mncourts.gov/forms
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j. k.
Is the wife now pregnant?
NO
YES, the due date is: _______________________. NO YES. If custody is disputed,
Is the issue of legal or physical custody contested?
each party shall submit proposals for custody and parenting time for each child as Exhibit 1A.
2.
EMPLOYMENT: Provide the following data for each employer. Attach prior month(s) paycheck stub(s) as Exhibit 2A. a. Name of Employer Length of Employment b. Income: (1) Gross Income per Month (Monthly income is to be calculated using a 4.3 multiple) Statutory Deductions: Federal Income Tax State Withholding $ _____________ $ _____________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ _____________ $ ________________ Husband ________________________ ________________________ Wife _________________________ _________________________
(2)
Social Security (FICA) and Medicare $ _____________ Pension Deduction Union Dues Dependent Health/ Hospitalization Coverage Dental Coverage (3) (4) Subtotal Statutory Deductions Net Income (line 1 subtract line 3) (5) Other Paycheck Deductions (specify) ______________________ ______________________ (6) (7) Subtotal Other Deductions NET TAKE HOME PAY (line 4 subtract line 6) $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________
$ ________________ $ ________________ $ ________________ $ ________________ $ ________________
$ ________________ $ ________________ $ ________________ $ ________________ $ ________________
c.
Tax withholding figures above are based on Married/Single taxpayer status with what number of
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DIV105
deductions? (Example: M-4 or S-2) d. Will your medical and dental insurance coverage be available for your spouse and children after the dissolution? Other Income: (1) Public Assistance (AFDC/GA) (2) Social Security Benefits for party or child(ren) (3) Unemployment/Workers Comp. (4) Interest paid per _____________ (5) Dividend paid per ___________ (6) Gross Rental Income (7) Other Income (specify): ____________________________ ____________________________ f.
______________
_________________
YES
NO
e.
$ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________
$ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________
List all employment benefits received, including but not limited to bonuses paid or due, automobile or travel expense reimbursement, other per diem compensation, and memberships paid by the employer: Petitioner: __________________________________________________________________ __________________________________________________________________________ Respondent: ________________________________________________________________ __________________________________________________________________________
3.
CHILD SUPPORT/SPOUSAL MAINTENANCE: a. As a result of a different case, Petitioner (check one): (check one or both): child support maintenance. pays receives
If an amount is paid or received, the amount paid/received each month for child support is $ issued in is not an arrearage b. and for maintenance is $ County, dated is an arrearage in the amount of $ pays according to the Order and there (check one): . receives
As a result of a different case, Respondent (check one): (check one or both): child support maintenance
If an amount is paid or received, the amount paid/received each month for child support is $ and for maintenance is $ according to the Order
DIV105
State
ENG
Rev
5/08-D
www.mncourts.gov/forms
Page 3 of 8
issued in (check one): c. is not an arrearage
County, dated is an arrearage in the amount of $ has not been issued
and
there .
In this proceeding a temporary order (check one): and includes an order for: (1) Child support to be paid by (check one): in the amount of $ is not an arrearage (2)
has been issued
Petitioner
Respondent
per month and there (check one): is an arrearage of $ Petitioner . Respondent
Maintenance to be paid by (check one): in the amount of $ is not an arrearage
per month and there (check one): is an arrearage of $ .
4.
LIVING EXPENSES: List your necessary monthly expenses: a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t. Rent Mortgage Payment Contract for Deed Payment Homeowner's Insurance Real Estate Taxes Utilities Heat Food Clothing Laundry and Dry Cleaning Medical and Dental Transportation (includes $ Car Insurance Life Insurance Recreation, Entertainment and Travel Newspapers and Magazines Social and Church Obligation Personal Allowances and Incidentals Babysitting and Day Care Home Maintenance
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$ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ car payment) $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________
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DIV105
u. v.
Child(ren)'s School Needs/Allowances Additional expenses (specify) _________________________
$ ________________
$ ________________ $ ________________
TOTAL MONTHLY EXPENSES:
5.
REAL PROPERTY: Provide the following information for real property owned by you and/or your spouse. If more room is needed, attach another sheet of paper labeled as Exhibit 5A. Homestead a. b. c. d. e. f. g. h. i. Date Acquired Purchase Price Present Fair Market Value First Mortgage Balance Second Mortgage Balance or Home Improvement Loan Net Value Monthly Payment (PITI) Rental Income, if any Title in name(s) of ___________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ ___________ Other Property $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ ________________
6.
PERSONAL PROPERTY: List the fair market value of the following person property: In Name or Possession of Husband a. b. Household contents Stocks, Bonds, etc. (list) _______________________ _______________________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ Wife $ __________ Both $ __________
c.
Checking Accounts (list) _______________________ _______________________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________
d.
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Receivables and Claims (list
State ENG Rev 5/08-D www.mncourts.gov/forms Page 5 of 8
_______________________ _______________________ e.
$ __________ $ __________
$ __________ $ __________
$ __________ $ __________
Motor Vehicles (cars, trucks, vans):
(1)Make/Model/Year (2)Make/Model/Year (3)Make/Model/Year
___________ Market Value Encumbrance Net Value Monthly Payment In possession of f. $ __________ $ __________ $ __________ $ __________ ___________
___________ $ __________ $ __________ $ __________ $ __________ ___________
___________ $ __________ $ __________ $ __________ $ __________ ___________
Boats, Motors, Campers, Snowmobiles, Trailer, etc.:
(1)Make/Model/Year (2)Make/Model/Year (3)Make/Model/Year
___________ Market Value Encumbrance Net Value Monthly Payment In possession of g. $ __________ $ __________ $ __________ $ __________ ___________
___________ $ __________ $ __________ $ __________ $ __________ ___________
___________ $ __________ $ __________ $ __________ $ __________ ___________
Other (such as power equipment, tools, guns, valuable animals, etc.):
(1) Description (2) Description (3) Description
Market Value Encumbrance Net Value In possession of
$ __________ $ __________ $ __________ ___________
$ __________ $ __________ $ __________ ___________
$ __________ $ __________ $ __________ ___________
7.
NONMARITAL CLAIMS: List all items you claim are your nonmarital property. Items Claimed as Nonmarital ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Value $________________________ $________________________ $________________________ $________________________
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DIV105
State
ENG
Rev 5/08-D
www.mncourts.gov/forms
8.
LIFE INSURANCE: List all insurance policies owned by you and your spouse. Policy 1 Company Policy Number Type (Whole or Term) Face Amount Cash Value Loan Balance Insured Beneficiary Owner ___________ ___________ ___________ $ __________ $ __________ $ __________ ___________ ___________ ___________ Policy 2 ___________ ___________ ___________ $ __________ $ __________ $ __________ ___________ ___________ ___________ Policy 3 ___________ ___________ ___________ $ __________ $ __________ $ __________ ___________ ___________ ___________
9.
PENSION PLAN AND/OR PROFIT-SHARING PLAN: a. Plans Through Employment: Present Cash Value Vested or Nonvested b. Private Plans (IRA, Keogh, SEP, etc.) Present Cash Value c. d. Deferred Compensation Military Pension or Disability $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ Husband $ __________ ___________ Wife $ __________ ___________
10. DEBTS: List all debts not already listed in paragraphs 4 or 5. If more room is needed, attach a schedule for secured debts labeled as Exhibit 10A and a schedule for unsecured debts labeled as Exhibit 10B. a. Secured Debts Creditor Balance Due When Incurred
DIV105 State ENG Rev 5/08-D
Debt 1 ___________ $ __________ ___________
Debt 2 ___________ $ __________ ___________
Debt 3 ___________ $ __________ ___________
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Party Obligated Reason for Debt Total Secured Debt: b. Unsecured Debts Creditor Balance Due When Incurred Party Obligated Reason for Debt Total Unsecured Debt:
___________ ___________
___________ ___________
___________ ___________
Husband$ _________ Wife$___________ Joint$ ___________ Debt 1 ___________ $ __________ ___________ ___________ ___________ Debt 2 ___________ $ __________ ___________ ___________ ___________ Debt 3 ___________ $ ___________ ___________ ___________
Husband$ _________ Wife$___________ Joint$ ___________
The statements made by me in this Prehearing Statement are true and correct to the best of my knowledge.
DATED:________________________
_________________________________________ Petitioner Respondent Signature of
_________________________________________ Signature of Attorney (if any) Attorney Name: ____________________________ Address: __________________________________ City/State:_________________________________ Telephone: Attorney I.D.: ______________________________
DIV105
State
ENG
Rev 5/08-D
www.mncourts.gov/forms
Page 8 of 8