State of Minnesota
Judicial District: Court File Number: Case Type:
Dissolution with Children
In Re the Marriage of:
Name of Petitioner
Petitioner's Respondent's Application for Temporary Relief With Children
Name of Respondent
STATE OF MINNESOTA COUNTY OF (County where Application signed) My name is (check one): Petitioner
) ) SS )
and I state under oath that I am the Respondent in this case, and in this Application for I understand that
Temporary Relief, I will be referred to as the: Husband Wife.
as I fill out this Application for Temporary Relief, I am under oath and must tell the truth. 1. The parties were married on (month/day/year) Wife's age is 2. years and the Husband's age is years. . The
The parties have been separated Wife Husband has paid $
month(s), during which time: to the: Wife Husband.
a. During the marriage, the following joint child(ren) were born to or adopted by the parties: Child's Address Child's Full Name Date of Birth Lives With (Street Address, City, (first, middle, last) State, Zip Code)
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b. The family home is: owned rented The family home is now occupied by:
by the parties.
Wife Husband Both parties.
Other person(s) live in the home (please specify): c. It is in the best interests of the joint child(ren) that the joint child(ren) be in the physical custody of the wife husband your reasons) d. The wife has nonjoint child(ren) from a previous marriage or relationship. per month for the support of the nonjoint both parties because (specifically explain
The wife: pays receives $ e. The husband has
child(ren). These nonjoint children do do not live with the wife. nonjoint child(ren) from a previous marriage or relationship. per month for the support of the The husband: pays receives $
nonjoint child(ren). These nonjoint children do do not live with the husband. 4. The parties have the following assets: Description of Asset a. Car market value Balance due Year/Make b. Stocks, Bonds, Notes c. Cash and Savings d. Accounts Receivable e. Homestead/Real Estate $ $ $ $ Wife uses or in wife's name $ $ / $ $ $ $ Husband uses or in Husband's name $ $ / $ $ $ $ Both use or in both names $ $ /
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Secured debts (not including those listed above and not including homestead; attach additional sheets, if necessary): Name of Creditor Balance Due $ $ $ $ $ $ $ $ $ $ Monthly Payment Party Obligated Security Pledged
Necessary Monthly Expenses (for you and the child(ren) if the child(ren) live with you): Monthly Expense a. Rent b. Mortgage payment c. Contract for Deed payment d. Homeowner's insurance e. Real Estate taxes f. Utilities g. Heat h. Food i. Clothing j. Laundry and Dry Cleaning k. Medical and Dental l. Transportation m. Car Insurance n. Life Insurance o. Recreation/Travel p. Newspapers/Magazines q. Social, Church obligations r. Personal Allowances/Incidentals s. Babysitting and Day Care $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Wife/Husband Expenses Child(ren) Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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t. Home Maintenance u. Child(ren)'s School Needs v. Child(ren)'s Allowances w. Additional info (explain):
$ $ $ $ $ $
$ $ $ $ $ $
TOTAL MONTHLY EXPENSES 7. My gross monthly income is $ My spouse's gross monthly income is $
$ from from
I have filed a Financial Affidavit for Child Support with the court, containing my gross income and required proof such as pay stubs or tax returns. 8. a. $ support for b. $ support for c. $ spousal maintenance. d. Payment should be made on the first (1st) and fifteenth (15th) of each month starting on (month, day, year) 9. a. $ b. $ c. $ costs. 10. Additional Material Facts: has been paid on wife's attorney's fees and costs. has been paid on husband's attorney's fees and costs. is reasonable for the: Wife's Husband's attorney's fees and . per month is a reasonable amount to be paid by me for temporary (number of) joint child(ren). per month is a reasonable amount to be paid to me for temporary (number of) joint child(ren). per month is a reasonable amount to be paid to me for temporary
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Based upon the above information, I ask the Court for an Order granting such relief prior to trial as may be just and lawful.
Dated: Signature of: Petitioner Respondent
(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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