Free STATE OF MINNESOTA__________________________ DISTRICT COURT - Minnesota


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Date: June 18, 2008
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State: Minnesota
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http://www.courts.state.mn.us/forms/public/forms/Divorce__Dissolution/General_Divorce/DIV105.pdf

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Preview STATE OF MINNESOTA__________________________ DISTRICT COURT
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
State ENG Rev 5/08-D

$ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ 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.
DIV105

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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www.mncourts.gov/forms

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

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