Free State of Minnesota - Minnesota


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Date: April 17, 2009
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State: Minnesota
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URL

http://www.courts.state.mn.us/forms/public/forms/Divorce__Dissolution/Petition_for_Divorce_with_Children/DIV802.pdf

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

District Court

Dissolution with Children

In Re the Marriage of:
Name of Petitioner (first, middle, last) and Name of Respondent (first, middle, last) STATE OF MINNESOTA ) COUNTY OF )SS (County where Petition is signed)

Petition For Dissolution Of Marriage With Children

1. Information about Petitioner Full Name: ________________________________________________________________________
First Middle Last

Address where you live:
Street Address Apt. No. _______ City County State Zip Code

Mailing address where you agree to receive papers for this case: Same as above address OR ________________________________________________________________________

Street Address City County State

Apt. No. _______ Zip Code

Date of Birth: ________________________
Month Day Year

Petitioner is the

husband

wife.

List all of Petitioner's former or other names or write "None":

First

Middle

Last

First

Middle

Last

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2.

Information about Respondent
First Middle Last

Full Name: Address:
Street Address Apt. No.

City

County

State

Zip Code

Respondent's address is unknown to Petitioner. Respondent's Date of Birth: ________________________
Month Day Year

List all of Respondent's former or other names or write "None":
First First Middle Middle Last Last

3.

Our Marriage Petitioner and Respondent were married on: (month, day, year) ,

in the City of _____________________, County of _______________________________, State of __________________________, Country of .

4.

180 Day Requirement Has Petitioner been living in Minnesota for the past six (6) months? Has Respondent been living in Minnesota for the past six (6) months? YES NO UNKNOWN YES NO

5.

Armed Forces Is Petitioner an active duty member of the armed forces? YES NO YES NO

If YES, has Petitioner been stationed in Minnesota for the past six (6) months?

Is Respondent an active duty member of the armed forces?

YES

NO

Unknown YES NO

If YES, has Respondent been stationed in Minnesota for the past (6) months?

6.

Marriage Cannot be Saved There has been an irretrievable breakdown of my marriage relationship with Respondent and the marriage cannot be saved.

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7.

Physical Living Situation Do Petitioner and Respondent live together at this time? If NO, the date we separated was:
Month Day Year

YES

NO .

If YES, why are you living together at this time?

8.

Other Proceedings a. Has a separate court case for marriage dissolution, legal separation, custody, paternity or annulment already been started by Petitioner or Respondent in Minnesota or elsewhere? NO If YES, the type of court case is: YES ,

and it was started in ________________________ County in the State of ____________________ and the Court file number is Open Closed I do not know , and the status or outcome of the case is:

b. Has a County started a Support case involving the Petitioner and the Respondent or their children? YES NO If YES, the case was started in ________________________ . Pending.

County in the State of ____________________ and the Court file number is A copy of the Support Order is attached, or the case is Dismissed, or

9.

Protection or Harassment Order Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and Respondent? If YES: a. The Order protects: in Petitioner Respondent the child(ren) and the Order was filed State on . A copy of the YES NO

County in date, and the Court file number is

Order is attached. b. Does the Order for Protection include an order to pay child support? YES NO

10.

Juvenile Court Case Is a Juvenile Court case (child protection, delinquency or foster care) involving husband's and wife's child(ren) taking place in Minnesota or another state? YES NO

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If YES, the case is in Court file number is in the Juvenile Court case is:

County in the State of __________________ and the . The name of the child or children involved

.

11.

Children Husband and Wife have Together (Joint Children)
"Child" means a living person under age 18, or under age 20 and still in high school.

a. Are there any children born to or adopted by husband and wife together, either before or during the marriage? YES NO If YES, Child Currently Lives With Petitioner Respondent Both parents OR _______________________(write in name) Respondent Both parents

Full Name of Child Date of Birth Age

Petitioner OR

________________________(write in name) Respondent Both parents

Petitioner OR

________________________(write in name) Respondent Both parents

Petitioner OR

________________________(write in name) Respondent Both parents

Petitioner OR

________________________(write in name)

If a child is living with someone other than a parent, write the child's address below: Address: ______________________________________________________________________
Street Address Apt. No.

City

County

State

Zip Code

b. Has each child born to or adopted by husband and wife together lived in Minnesota for the past six (6) months? YES NO

If NO, name the child or children, name the State(s) the child has lived in during the past 6 months, and the dates the child lived in each state:

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12.

Adult Dependent Children
Support can be ordered for a joint child over age 18 who cannot support him/herself because of a physical or mental condition.

Is there an adult joint child born to or adopted by Husband and Wife who is not able to support himself or herself because of a physical or mental condition? YES NO

If YES, the full name, date of birth and age of each adult dependent is: Full Name of Dependent Date of Birth

Age

13.

Pregnancy a. b. Petitioner Is wife pregnant? Respondent is the wife in this marriage. YES NO UNKNOWN

If wife is pregnant answer (i) and (ii): (i) The date the baby is due is
Month Day Year

OR

UNKNOWN

(ii) Do Wife and Husband agree that husband is the biological father of the unborn child? YES If NO, NO Wife Husband claims husband is not the biological father of the child,

and Petitioner asks the Court to issue a separate order setting a hearing date for after the birth of the child to determine Paternity, unless appropriate Recognition of Parentage documents are signed by husband, wife and the biological father after the birth of the child. 14. Husband's Children from Other Relationship (Non-Joint Children) Does Husband have minor child(ren) from another marriage or relationship? YES NO UNKNOWN

If YES, the full name, date of birth and age of each child is: Full Name of Child and Age Date of Birth Does Child Live with Husband? YES NO YES YES YES YES
DIV802 State ENG Rev 4/09

Is Husband Court-Ordered to pay Child Support for this Child? YES NO YES YES YES YES NO NO NO NO
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NO NO NO NO

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15.

Wife's Children from Other Relationship (Non-Joint Children) a. Does Wife have minor child(ren) born prior to the marriage from another marriage or relationship? YES NO UNKNOWN

If YES, the full name, date of birth and age of each child born prior to the marriage is: Full Name of Child and Age Date of Birth Does Child Live with Wife? YES NO YES YES YES NO NO NO Is Wife Court-Ordered to pay Child Support for this Child? YES NO YES YES YES NO NO NO

b. Has Wife given birth, since marrying Husband, to a minor child who is not a child of the Husband? YES NO

If YES, answer (i) , (ii), (iii) and ( iv): (i) List the full name, date of birth and age of each child born to Wife since marrying Husband, who is not a child of the Husband: Full Name of Child and Age Date of Birth Does Child Live with Wife? YES NO YES NO Is Wife Court-Ordered to pay Child Support for this Child? YES NO YES NO

(ii)

Is there a Court Order naming someone other than the Husband as the father of the child(ren) listed in (i) above? YES NO
Full Name of Child(ren)

If YES, attach a copy of the Order. The Order is for: _______________________

(iii)

Have the Wife and biological Father signed a Minnesota Recognition of Parentage for any of the children listed in (i) above? If YES, state the full name of the child: attach a copy of the Recognition of Parentage. If NO, why not? YES NO and

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(iv)

Has the Husband signed the "Husband's Non-Paternity Statement " for any of the children listed at (i) above? YES NO

If YES, state the name of the child: and attach a copy of the "Husband's Non-Paternity Statement." If NO, why not?

16. Parenting Time Petitioner's parenting time with the joint children should be: (check one) unsupervised supervised reserved

Respondent's parenting time with the joint children should be: (check one) unsupervised supervised reserved

If parenting time is unsupervised for both parents, skip to Question 17.

For supervised parenting time answer a. and b. For reserved parenting time, answer c. a. Explain how unsupervised parenting time is likely to endanger the child's physical or emotional health or impair the child's emotional development:

b. State who should supervise parenting time, and if there is a cost involved, who should pay the cost, and any other important details:

c. Explain why parenting time should be reserved:

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17.

Public Assistance from State of Minnesota
If either party is receiving public assistance from the State of Minnesota or applies for it after this proceeding is started, the Petitioner must give notice of this marriage dissolution action to the Support and Collections office for the county paying the assistance.

a. Does Petitioner receive public assistance from the State of Minnesota?

YES

NO

If YES, the assistance is from __________________ County. (Check all that apply): MFIP in the amount of $___________per month Tribal TANF in the amount of $__________per month General Assistance in the amount of $___________per month Child Care Assistance MinnesotaCare Medical Assistance

b. Does Respondent receive public assistance from the State of Minnesota? YES NO UNKNOWN

If YES, the assistance is from __________________ County. (Check all that apply): MFIP in the amount of $___________per month Tribal TANF in the amount of $__________per month General Assistance in the amount of $___________per month Child Care Assistance MinnesotaCare Medical Assistance

c. Do the joint children of the parties receive public assistance from the State of Minnesota? YES NO UNKNOWN

If YES, the assistance is from __________________ County. (Check all that apply): MFIP Medical Assistance Tribal TANF MinnesotaCare

IV-E Foster Care 18. Supplemental Security Income (SSI)
Supplemental Security Income (SSI) is a Federal income supplement program. It is available to low-income people if they are over age 65, or blind, or disabled.

a.

Does Petitioner receive Supplemental Security Income (SSI)? of $___________per month.

NO

YES in the amount

b.

Does Respondent receive Supplemental Security Income (SSI)? amount of $___________per month.

NO

YES in the

c.

Do any of the joint children of the parties receive Supplemental Security Income (SSI)? NO YES in the amount of $___________per month. What is the name of the child

Receiving SSI?____________________________________________________________

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19.

School Is Petitioner currently enrolled in school? a. The name of the school is b. The type of school is High School College Vocational Other YES NO If Yes: .

c. The type of degree expected is____________________________and the expected graduation date is __________________________. Is Respondent currently enrolled in school? a. The name of the school is b. The type of school is High School College Vocational Other YES NO UNKNOWN If Yes: .

c. The type of degree expected is____________________________and the expected graduation date is __________________________. Petitioner's Employment a. Is Petitioner employed? YES NO Is Petitioner Self-Employed? YES NO YES NO

20.

b. Is Petitioner working at least 40 hours per week?

If you are unemployed or working less than 40 hours/week, answer these questions: i. Explain why you are not working or why you work less than 40 hours/week.

ii. What is your past work experience (type of jobs, hours, pay, length of time at the job) and what are your professional qualifications or licenses?

c.

Current Employment: (If Petitioner has more than two jobs at this time, use an attachment for the additional jobs.) ____________________________________________________________________________
Name of Petitioner's Employer (If Self-Employed, list name and business address)

____________________________________________________________________________
Employer's Street Address
City State Zip Code

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Name of Petitioner's Employer (If Self-Employed, list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

Questions about Current Jobs Are you paid by the hour or do you have a salary? What is the average number of hours you work per week? How much overtime pay do you receive per week on average? Do you receive bonuses? Yes No

1st Job hourly salary

2nd Job hourly salary

________________hours

________________hours

$_____________________

$____________________

If Yes, how much did you receive in If Yes, how much did you receive in bonuses last year? $_____________ bonuses last year? $_____________

How much do you expect to receive How much do you expect to receive this year? $___________ this year? $___________

21. Petitioner's Income NOTE: There is a separate form called "Financial Affidavit" which you must fill out, serve on your spouse, and file with the court at the time you file this Petition. You must attach proof of your income to the Financial Affidavit.
If you do not have income in a category, enter zero (0). Do not list public assistance benefits as income (e.g. MFIP, GA, SSI).

Source of Income Self Employment Income

Amount Per Month (before deductions/taxes) $________________ (or zero)

Self Employment income means gross receipts minus costs of goods sold minus ordinary and Necessary business expenses. Attach Schedule "C" from last year's tax return to this Petition.

Job with __________________________ Second Job with _____________________ Third Job with ______________________ Commissions from all jobs

$________________per month $________________ per month $________________ per month $________________ per month

Your monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Divide the total amount you expect this year by 12 to get a monthly average

Unemployment benefits
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$________________ per month
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Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) $_________________per month Investment and Rental Income Annuity payments Pension or Disability from work or military Worker's Compensation Court-ordered spousal maintenance you receive Other income____________________________
Identify Source

$________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month

Add all of the above. Total monthly income Enter the amount of child support you are court-ordered to pay for any nonjoint child(ren)

$ ________________ per month

$________________per month

Enter the amount of spousal maintenance you are court-ordered to pay to your current or former spouse $_______________per month Enter the amount of Social Security or Veteran's Benefits provided to a joint child because of your retirement, disability, or other eligibility $________________ per month If you entered an amount, which parent receives the payment for the child? Petitioner Respondent

22.

Living Expenses for the Family a. Petitioner and Respondent and our children are still living together. Our current monthly living expenses for our family total $ OR b. Petitioner and Respondent are living separately. Our monthly family living expenses before we separated totaled $ . At this time, Petitioner's separate monthly .

living expenses total $____________, and Respondent's monthly living expenses total $______________or are unknown to Petitioner. Of the total current monthly living

expense for Petitioner, what dollar amount is for expenses just for the children that live with Petitioner? $_________________. Of the total current monthly living expenses for

Respondent, $___________is for expenses just for the children that live with Respondent, or this is UNKNOWN.

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23. Expenses for Special Needs for the Children a. Is there a child of the parties who has special needs and extraordinary medical expenses? YES NO If Yes,

Name of child with special needs: Describe the needs:

b. Does Petitioner's monthly living expense (stated at #22) include the special needs expenses for the child? YES NO c. Does Respondent's monthly living expense (stated at #22) include the special needs expenses for the child? 24. YES NO Respondent's Employment a. Is Respondent employed? b. Is Respondent Self-Employed? YES NO YES NO UNKNOWN UNKNOWN YES NO UNKNOWN

c. Is Respondent working at least 40 hours per week?

If Respondent is unemployed or works less than 40 hours/week, answer these questions: i. Explain why Respondent is not working or why Respondent works less than 40 hours/week

ii. What is Respondent's past work experience (type of jobs, hours, pay, length of time at the job) and professional qualifications or licenses?

c. Current Employment: (If Respondent has more than two jobs at this time, use an attachment for the additional jobs.)

____________________________________________________________________________
Name of Respondent's Employer (If Self-Employed list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

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___________________________________________________________________________
Name of Respondent's Employer (If Self-Employed list name and business address)

____________________________________________________________________________
Employer's Street Address

City

State

Zip Code

Questions about Jobs Is Respondent paid by the hour or salaried?

1st Job hourly Unknown salary

2nd Job hourly Unknown ________________hours Unknown salary

What is the average number of hours ________________hours Respondent works per week? How much overtime pay does Respondent receive per week on $_____________________ average? Does Respondent receive bonuses? Yes No Unknown Unknown Unknown

$____________________ Unknown

If Yes, how much did Respondent If Yes, how much did Respondent receive in bonuses last year? receive in bonuses last year?

$___________

$_________

How much does Respondent expect How much does Respondent expect to receive this year? $___________ to receive this year? $___________

25.

Respondent's Income Petitioner has no information about Respondent's income OR Petitioner does not have detailed information about Respondent's income, but has good reason to believe that Respondent's pay is $________________ per week month

year, with bonuses, overtime or commissions in the additional amount of $________________ per week month year. This is Respondent's Net

Income (after taxes and deductions) or OR

Gross Income (before taxes and deductions.)

Petitioner has detailed information about Respondent's income. If this is true, fill out the income information below.

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If Respondent has no income in a category, enter zero (0). Do not list public assistance benefits as income (e.g. MFIP, GA, SSI).

Respondent's Source of Income Self Employment Income

Amount Per Month (before deductions/taxes) $___________________ (or zero)

Self Employment Income means gross receipts minus costs of goods sold minus ordinary and necessary business expenses. Attach Schedule C from last year's tax return to this Petition, if available.

Job with______________________________ Second job with________________________ Commissions from all jobs Unemployment benefits

$ ___________________ per month $____________________ per month $____________________ per month $____________________ per month

Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Divide the total amount expected this year by 12 to get a monthly average

Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) Investment and Rental Income Annuity payments Pension or Disability from work or military Worker's Compensation Court-ordered spousal maintenance received by Respondent Other income____________________________
Identify Source

$____________________ per month $____________________ per month $_____________________ per month $_____________________ per month $_____________________ per month $____________________ per month $____________________ per month

Add all of the above.

Total monthly income

$ ____________________ per month

Enter the amount of child support Respondent is court-ordered to pay for any nonjoint child(ren) $____________________ per month Enter the amount of spousal maintenance Respondent is court-ordered to pay to a current or former spouse $____________________ per month Enter the amount of Social Security or Veteran's Benefits provided to a joint child because of Respondent's retirement, disability, or other eligibility $_____________________ per month If you entered an amount, which parent receives the payment for the child? Petitioner Respondent

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26.

Child Care Costs Are there child care costs for the joint children because of work or school? YES NO

If YES, attach to this Petition a receipt or signed letter from the child care provider showing the cost of child care, and answer (a) (b) and (c): a. How many of your joint children need child care? One Two Three __________

b. How much does the daycare center(s) or babysitter charge per month? $
(If you pay by the week, multiply the weekly charge by 4.33 to get the charge per month. If costs vary during the year, use the total yearly costs and divide by 12.)

c.

Who pays the child care costs? Petitioner pays $ per month Respondent pays $ per month The County pays $ per month through a subsidy or child care assistance. If the County pays, who applied for the child care assistance? Petitioner Respondent There is no county assistance

27.

Health Care Coverage a. Minnesota Care and Medical Assistance are available from the State of Minnesota for people who qualify. Who receives Minnesota Care or Medical Assistance? Petitioner Respondent Joint Children No one

b. Does Petitioner currently have medical insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to c. i. Where does Petitioner get the medical insurance? through his/her employment buys private medical insurance ii. How much does the medical insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage iii. Who is currently covered by this medical insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered_____________________________________

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c. Does Petitioner have dental insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to d.

i. Where does Petitioner get the dental insurance? through his/her employment buys private dental insurance ii. How much does the dental insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage Or, Dental is included in the medical insurance costs.

iii. Who is currently covered by this dental insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered____________________________________

d. Does Respondent have medical insurance? (other than MN Care or Medical Assistance) Yes No Unknown. If No/ Unknown, skip to e. i. Where does Respondent get the medical insurance? through his/her employment buys private medical insurance ii. How much does the medical insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage iii. Who is currently covered by this medical insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered____________________________________

e. Does Respondent have dental insurance? (other than MN Care or Medical Assistance) Yes No Unknown If No/ Unknown skip to f. i. Where does Respondent get the dental insurance? through his/her employment buys private dental insurance ii. How much does the dental insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered)
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$____________per month for family coverage Or, Dental is included in the medical insurance costs.

iii. Who is currently covered by this dental insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered_____________________________________

f. If the joint children are without health care coverage, is coverage available for purchase through Petitioner's or Respondent's employer? coverage YES NO The children currently have health

28.

Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.

Check only one box: Petitioner and Respondent can each pay their own living expenses and do not need spousal maintenance at this time, or in the future. Petitioner or Respondent may need spousal maintenance in the future. The court should reserve maintenance to allow either party to ask for spousal maintenance in the future because: (explain why you want to do this)

Petitioner needs spousal maintenance from Respondent now. Petitioner is __________years of age, Petitioner and Respondent have been married for _________years. Petitioner has the following education:_____________________________________________. Petitioner's gross monthly income totals $__________________. Petitioner's monthly expenses total $______________ and Petitioner is not able to maintain the standard of living established during the marriage because: _______________________________________________________ Respondent has the ability to pay Petitioner $_____________per month for spousal maintenance. Respondent needs spousal maintenance from Petitioner now. Respondent is __________years of age, Petitioner and Respondent have been married for _________years. Respondent has the
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following education:_____________________________________________. Respondent's gross monthly income totals $______________. Respondent's monthly expenses total $________________, and Respondent is not able to maintain the standard of living established during the marriage because: _______________________________________ Petitioner has the ability to pay Respondent $_____________per month for spousal maintenance. .

29. Vehicles
Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles etc. owned by husband or wife together or separately, including vehicles purchased after separation:

Does Petitioner own a vehicle? Does Respondent own a vehicle?

YES YES

NO NO UNKNOWN

List all vehicles owned by husband or wife together or separately: Type of Vehicle (car, boat, truck etc.) Year/Make/ Model Name(s) on Title $ $ $ $ 30. Marital Property
Marital property means almost anything that you or your spouse now own that was received or bought during the marriage, even during the times you were separated. Marital Property includes household goods, furniture, jewelry, boats, real estate and other things. Marital property does not include a gift or inheritance received by one spouse alone.

Value

Balance Owed

Monthly Payment

$ $ $ $

$ $ $ $

Has the marital property been divided already to the Petitioners' satisfaction? If NO, Petitioner requests the following marital property:

YES

NO

________________________________________________________________________________ ________________________________________________________________________________ 31. Non-Marital Property
Non-marital property means: (1) anything that you or your spouse owned before the marriage; (2) anything that you or your spouse received as a gift, bequest, devise, or inheritance, to you or your spouse alone; (3) anything that you or your spouse got in trade or in exchange for your non-marital property; (4) anything that is an increase in the value of non-marital property; (5) anything you or your spouse received after the

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valuation date set by the court; or (6) anything defined as non-marital property by a valid antenuptial contract.

a.

Does Petitioner have non-marital property? If YES, list Petitioner's non-marital property:

YES

NO

b.

Does Respondent have non-marital property?

YES

NO

UNKNOWN

If YES, list Respondent's non-marital property:

___________________________________________________________________________. 32. Cash & Accounts Not including Pension and Employer-Funded Retirement Accounts Does Petitioner have money in banks, savings, cash or investments? Does Respondent have money in banks, savings, cash or investments? If YES, a. List all accounts owned by you alone, your spouse alone, or owned by both of you jointly including those opened after separation. "Type of account" means checking, savings, money market accounts, certificates of deposit, stocks, bonds, stock options, mutual funds, savings bonds, and Treasury Bills, etc. Do not include Pension or Employer-Funded Retirement Accounts, which are listed at #36. Financial Institution Type of Account Account #
Last 4 digits only

YES
YES

NO
NO UNKNOWN

Amount

Belongs to:
(name on account)

XX XX XX XX XX XX b. List cash not listed at a.: Petitioner has cash in the amount of $ Respondent has cash in the amount of $ 33. Business Interest Does Petitioner have an interest in a business?
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$ $ $ $ $ $

. OR UNKNOWN.

YES

NO
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Does Respondent have an interest in a business?

YES

NO

UNKNOWN

If YES, the name of the business is ____________________________, the address is ________________________________________________________________________________ and the value is $________________. How did you arrive at this value?

34.

Manufactured Home Does Petitioner own a manufactured home? Does Respondent own a manufactured home? YES YES NO NO UNKNOWN

If either Petitioner or Respondent own a manufactured home, together or separately, complete the following information: a. Address of the manufactured home: in the city of , state of

b. What type of home is it? (single, double-wide etc.) c. Whose name(s) is on the title? d. When was the home purchased? e. What was the purchase price? $

f. What is the current values of the home? $ g. How did you arrive at that amount as the current value?

h. How much money is still owed on the home? $ i. If money is owed on the home, who is the money owed to? j. Do you own the land the home sits on, or do you rent a lot? Rent Own

Note: If you own the lot, you must list the land at Paragraph 35. 35. Real Property - Land, Buildings, Contracts for Deed
All real property now owned by Petitioner or Respondent together or separately must be listed. Include real property acquired before the marriage, during the marriage, and after separation.

a. b.

Do Petitioner and Respondent jointly own real property?

YES

NO

Does Petitioner own real property solely in his/her own name or with someone other than Respondent? YES NO

b.

Does Respondent own real property solely in his/her own name or with someone other than Petitioner? YES
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NO

UNKNOWN
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c.

How many properties are owned by you and your spouse in total? Three _______

None

One

Two

If you or your spouse own real property, separately or together, complete the following information about the property. If there is more than one piece of real property, photocopy and complete a Real Property Information page for each piece of property. Staple the

additional sheets to this Petition, and label each sheet "Attachment to Petition of ____________________(your name)"

Real Property Information 1. Real Estate belongs to: (List full names of all owners)_____________________________________ ________________________________________________________________________________ 2. Legal Description is: (The full legal description must be included. Copy the legal description from the deed. Do not use the property tax statement legal description. If the legal description is long, you may use an attachment. Type or print neatly.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Street Address of the real property is: ________________________________________________________________________________ City______________________________________State______________Zip Code______________ The property is in_____________________________________County. 4. Purchase date_________________(month , day, year) and purchase price:$ 5. Mortgages or loans: (List all mortgages and loans on the property) There are no mortgages or loans on this property. 1st Mortgage: Amount currently owed $ 2nd Mortgage: Amount currently owed $ and name of lender _______

and name of lender

Other mortgages or loans:

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6. Current Market Value of this property: How did you arrive at this value?

$___________________________________

7. This property is the homestead: _______Yes

_________No

36.

Retirement Plans a. Does Petitioner have a retirement account? (IRA, 401(k), 403(b) or other) YES NO If YES:

a) The account number is: (last 4 digits only) b) The name of the bank that has the account is: c) The current account balance is: b. Has Petitioner, or Petitioner's past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Petitioner? YES If YES: a) The name of the plan is:____________________________________________________ b) The employer, union or group providing the plan is: c) The date Petitioner began working at the job or joined the union or group plan is: NO

d) The type of plan is: (e.g. defined benefit, defined contribution)

e) The present value of the pension or plan is: c. Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other) YES If YES: a) The account number is: (last 4 digits only) b) The name of the bank that has the account is: c) The current account balance is: d. Has Respondent, or Respondent's past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Respondent? YES NO UNKNOWN NO UNKNOWN

If YES, and it is a Pension, Profit-Sharing, or other Retirement Plan:
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a) The name of the plan is: b) The employer, union or group providing the plan is: c) The date Respondent began working at the job or joined the union or group plan is:

d) The type of plan is: (e.g. defined benefit, defined contribution)

e) The present value of the pension or plan is: ___________________________________ 37. Debts Does Petitioner have debt? Does Respondent have debt? YES YES NO NO UNKNOWN

If YES, list debts in your name, your spouse's name and in both names jointly. Include unpaid debts from before the marriage date, during the marriage, and after separation. Fill in all information completely and attach another sheet of paper if necessary. Money is owed to: Money was used Whose Name is on the Account for: and When was the Debt Incurred? Name Date $ $ $ $ $ $ $ $ $ Balance Owed Monthly Payment

$ $ $ $ $ $ $ $ $

Total Debt 38. Name Change

$ $

$ $

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Does Petitioner want to change his/her name? below: a. Petitioner's name should be changed to

YES

NO If YES, answer (a) through (c)

First

Middle

Last

Is this name a former legal name or maiden name?

YES

NO

If NO, the reason

Petitioner wants to change to this name is: _________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ b. Petitioner has no intent to defraud or mislead anyone by changing his/her name: True c. False YES NO If YES, answer i. and ii:

Has Petitioner been convicted of a felony?

i. Petitioner has given notice of this request for name change to the proper authority as required by Minn. Stat. Section 259.13. (See Felon Name Change Instructions) ii. Petitioner has attached to this Petition an Affidavit of Service of the Notice marked Exhibit "A". 39. Other Include other facts you think the Court should know.

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

BASED UPON THE ABOVE INFORMATION, Petitioner requests that the Court issue a final judgment and decree granting the following relief:

1. 2.

Dissolving the bonds of matrimony between Petitioner and Respondent to end the marriage. Legal Custody : Legal Custody means which parent(s) have a say in the major decisions regarding
the child(ren)'s life including education, religious upbringing and medical treatment.

Granting legal custody of each minor child of the parties as follows: Name of Child Granting Legal Custody: Solely to Petitioner OR both parties. Solely to Petitioner OR to both parties.
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Solely to Respondent OR

Jointly to

Solely to Respondent OR

Jointly

Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties.

Solely to Respondent OR

Jointly

Solely to Respondent OR

Jointly

Solely to Respondent OR

Jointly

3.

Physical Custody: Physical custody identifies which parent(s) will handle the routine daily care and
control of the child(ren).

Granting physical custody of each of the minor children of the parties as follows: Name of Child Granting Physical Custody: Solely to Petitioner OR both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly to

4.

Parenting Time a. Petitioner's parenting time shall be: b. Respondent's parenting time shall be: Unsupervised Unsupervised Supervised Supervised Reserved Reserved

c. Parenting Time Schedule shall be as follows: (Clearly explain the time each parent will spend with each child. Include the time (o'clock) when the child will transfer from one parent to the other. If you want the order to say who will pick up and drop off the child, include that under "Other.") Regular schedule: Monday through Friday:

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Weekends:

Summer (if you want a different schedule in summer)

Telephone contact with the child(ren):

Unlimited or

Only at certain times as follows:

(describe the days and times when the parent and child(ren) may have telephone contact)

Exceptions to the Regular Schedule: You can have a different schedule for holidays, school release days, and birthdays. If you do not want a different schedule, leave it blank. School Release days or breaks during the school year

Any school release day schedule will supercede the regular parenting schedule.

Birthdays (child's birthday, parent's birthday)

Holidays

Any holiday or birthday schedule will supercede the regular and school release parenting schedule. Other

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d. Under the above Schedule: The children are with Petitioner: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time

The children are with Respondent: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time

5.

Child Support Ordering the payment of child support based on each parent's income. If either parent fails to provide income information, the court will set child support based on the available evidence and Minnesota law.

6.

Health Care Coverage for the Joint Children Choose a, b, or c. a. Petitioner Respondent shall provide medical insurance for the joint minor child(ren):

through his/her employer or union OR by obtaining and paying for private insurance. Petitioner Respondent shall provide dental insurance for the joint minor child(ren):

through his/her employer or union OR by obtaining and paying for private insurance. The other parent must contribute to the costs of health coverage as required by law. OR b. If Medical Assistance or Minnesota Care is open for the child(ren), ordering the non-custodial parent to make a sum certain payment as reimbursement through income withholding through the Minnesota Child Support Payment Center. OR c. Reserving the issue of medical and dental insurance for the minor children. d. Other: ____________________________________________________________

________________________________________________________________________ ________________________________________________________________________.

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7.

Unreimbursed Medical and Dental Costs for the Children
"Unreimbursed medical and dental costs" are expenses not covered by insurance, not paid by medical assistance, and not paid by the State of Minnesota. Examples include deductibles, co-pays, and procedures not covered by insurance or assistance. Choose a. or b.

a. Ordering each parent to pay a share of the unreimbursed medical and dental costs for the child(ren) of the parties, based on the relative incomes of the parties; OR b. Reserving the issue of unreimbursed medical and dental costs.

8.

Medical and Dental Insurance for the Parties a. Ordering each party to provide for his or her own medical dental insurance. medical dental

b. Ordering ____________________________(full name) to provide

insurance for ______________________________________________ (full name). c. Allowing____________________________(full name), at his/her own expense, to continue the dependent coverage available under the other party's insurance plan, pursuant to federal and state statutes. d. Reserving the issue of medical and dental insurance for the parties. 9. Child Care Expenses a. Ordering Petitioner and Respondent to each pay a share of the monthly child care expenses, according to Minnesota law; OR b. Reserving the issue of child care expenses.

10.

Spousal Maintenance a. Maintenance is denied to Petitioner and Respondent. b. Reserving the issue of maintenance.
c. Ordering Petitioner Respondent to pay spousal maintenance to Petitioner Respondent.

11.

Vehicles Awarding the vehicles as follows and ordering the party receiving the vehicles to pay for any loans or insurance for such vehicle: Year / Make / Model Awarded to:

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12.

Marital Property Dividing the parties' marital property, household goods, furniture and furnishings either: a. As currently divided OR b. As follows (attach additional page if necessary): To Petitioner:

To Respondent:

13.

Non-Marital Property Dividing the parties non-marital property a. As currently divided OR b. As follows (attach additional page if necessary): To Petitioner:

To Respondent:

14.

Cash and Accounts a. Awarding the savings, and investments as follows: Institution Type of Account Account #
(Last 4 digits only)

Amount $ $ $

Awarded to

XX XX XX

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XX XX XX

$ $ $

b.

Awarding any cash not included in a. above to the party who currently has the cash OR Awarding the cash as follows:

15.

Business None OR Awarding the parties' business as follows: _________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

16.

Manufactured Home None OR Awarding the manufactured home located at :
street address

city

state

to

Petitioner

Respondent. The debt on the manufactured home owed to: shall be paid by

Petitioner

Respondent.

17.

Real Property None OR Awarding solely to Petitioner Respondent all right, title, and interest of husband

and wife in the real property located at: Street address___________________________________________________________________ in the City of State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by
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Respondent: 1st Mortgage: Amount currently owed: $ 2nd Mortgage: Amount currently owed: $ and name of lender:

and name of lender:

and subject to the following liens or other agreements: A lien in favor of Petitioner Respondent in the amount of $ .

Other request regarding the property: (describe the request fully)

18.

Additional Real Property None OR Awarding solely to Petitioner Respondent all right, title, and interest of husband and

wife in the real property located at: Street address___________________________________________________________________ in the City of State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Respondent: 1st Mortgage: Amount currently owed: $ 2nd Mortgage: Amount currently owed: $ and name of lender: Petitioner

and name of lender:

and subject to the following liens or other agreements: A lien in favor of Petitioner Respondent in the amount of $ .

Other request regarding the property: (describe the request fully)

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19.

Retirement Funds a. Awarding Petitioner's pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: 100% to Petitioner OR

Dividing Petitioner's retirement benefits fairly and equitably between the parties. b. Awarding Respondent's pension, profit sharing, retirement plan, I.R.A.or 401(k) or other retirement fund as follows: 100% to Respondent OR Dividing Respondent's retirement benefits fairly and equitably between the parties.

20.

Debts a. Dividing the debts as follows and ordering each party to hold the other harmless from any responsibility for the debts so divided. Include all debts listed at 37 above. Debt Owed To: To Be Paid By:

b. Ordering that each party is solely responsible for paying any other debts incurred solely by him or her and ordering each party to hold the other harmless from any responsibility for such separately incurred debts.

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21.

Name Change Petitioner is not requesting a name change; OR Changing Petitioner's name to:
First Middle Last

22.

Other

23.

Ordering such other relief as the Court deems just and equitable.

24.

READ and SIGN the Verification and Acknowledgments.

STATE OF MINNESOTA

) ) SS COUNTY OF ) (County where Petition is signed) Verification and Acknowledgments a. I have read this document. To the best of my knowledge, information and belief the information contained in this document is well grounded in fact and is warranted by existing law. b. I have not been determined by any Court in Minnesota or in any other State to be a frivolous litigant and I am not the subject of an Order precluding me from serving or filing this document. c. I am not serving or filing this document for any improper purpose, such as to harass the other party or to cause delay or needless increase in the cost of litigation or to commit a fraud on the Court. d. I understand that if I am not telling the truth or if I am misleading the Court or if I am serving or filing this document for an improper purpose, the Court can order me to pay money to the other party, including the reasonable expenses incurred by the other party because of the serving or filing this document, Court costs, and reasonable attorney's fees. I understand that I could also be prosecuted for perjury if I am not telling the truth in my Petition.

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DATE: Month

/ Day

/ Year Petitioner's Signature (Sign only in presence of notary public)

Mailing Address (Street):

City, State Zip Code: Telephone: ( Subscribed and sworn to before me this ______day of _____________, ______. _______________________________ Notary Public or Court Clerk )

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