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Download Minnesota petition for dissolution of marriage with children Form

Forms in Divorce

Use this template/form as a petition for dissolution of marriage with children Form in the State of Minnesota

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minnesota-petition-for-dissolution-of-marriage-with-children

Text version of this Form

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

In Re the Marriage of:

Name of Petitioner (first, middle, last) Petition For Dissolution Of
Marriage With Children
and

Name of Respondent (first, middle, last)

STATE OF MINNESOTA )
COUNTY OF )SS
(County where Petition is signed)

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 Apt. No.
_______
City County State Zip Code

Date of Birth: ________________________ Petitioner is the husband wife.
Month Day Year

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

Full Name:
First Middle Last

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 Middle Last

First Middle 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? YES NO

Has Respondent been living in Minnesota for the past six (6) months?

YES NO UNKNOWN

5. Armed Forces

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

If YES, has Petitioner been stationed in Minnesota for the past six (6) months? YES NO

Is Respondent an active duty member of the armed forces? YES NO Unknown

If YES, has Respondent been stationed in Minnesota for the past (6) months? YES NO

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? YES NO

If NO, the date we separated was: .
Month Day Year
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? YES

NO If YES, the type of court case is: ,

and it was started in ________________________ County in the State of ____________________

and the Court file number is , and the status or outcome of the case is:

Open Closed I do not know

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 ________________________

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 Pending.

9. Protection or Harassment Order

Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and

Respondent? YES NO

If YES:

a. The Order protects: Petitioner Respondent the child(ren) and the Order was filed

in County in State on

date, and the Court file number is . A copy of the

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 County in the State of __________________ and the

Court file number is . The name of the child or children involved

in the Juvenile Court case is:

.

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,

Full Name of Child Date of Birth Age Child Currently Lives With
Petitioner Respondent Both parents

OR _______________________(write in name)

Petitioner Respondent Both parents

OR ________________________(write in name)

Petitioner Respondent Both parents

OR ________________________(write in name)

Petitioner Respondent Both parents

OR ________________________(write in name)

Petitioner Respondent Both parents

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. Petitioner Respondent is the wife in this marriage.

b. Is wife pregnant? YES NO UNKNOWN

If wife is pregnant answer (i) and (ii):

(i) The date the baby is due is OR UNKNOWN
Month Day Year
(ii) Do Wife and Husband agree that husband is the biological father of the unborn child?

YES NO

If 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 Date of Does Child Live Is Husband Court-Ordered to pay
and Age Birth with Husband? Child Support for this Child?
YES NO YES NO

YES NO YES NO

YES NO YES NO

YES NO YES NO

YES NO YES 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 Date of Does Child Live Is Wife Court-Ordered to pay
and Age Birth with Wife? Child Support for this Child?
YES NO YES NO

YES NO YES NO

YES NO YES NO

YES NO YES 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 Date of Does Child Live Is Wife Court-Ordered to pay
and Age Birth with Wife? Child Support for this Child?
YES NO YES NO

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

If YES, attach a copy of the Order. The Order is for: _______________________
Full Name of Child(ren)

(iii) Have the Wife and biological Father signed a Minnesota Recognition of Parentage

for any of the children listed in (i) above? YES NO

If YES, state the full name of the child: and

attach a copy of the Recognition of Parentage.

If NO, why not?

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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)? NO YES in the amount

of $___________per month.

b. Does Respondent receive Supplemental Security Income (SSI)? NO YES in the

amount of $___________per month.

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? YES NO If Yes:

a. The name of the school is .

b. The type of school is High School College Vocational Other

c. The type of degree expected is____________________________and the expected

graduation date is __________________________.

Is Respondent currently enrolled in school? YES NO UNKNOWN If Yes:

a. The name of the school is .

b. The type of school is High School College Vocational Other

c. The type of degree expected is____________________________and the expected

graduation date is __________________________.

20. Petitioner’s Employment

a. Is Petitioner employed? YES NO Is Petitioner Self-Employed? YES NO

b. Is Petitioner working at least 40 hours per week? YES NO

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

st nd
Questions about Current Jobs 1 Job 2 Job

Are you paid by the hour or do you hourly salary hourly salary

have a salary?

What is the average number of hours

you work per week? ________________hours ________________hours

How much overtime pay do you

receive per week on average? $_____________________ $____________________

Do you receive bonuses? If Yes, how much did you receive in If Yes, how much did you receive in

Yes No 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 Amount Per Month (before deductions/taxes)

Self Employment Income $________________ (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 __________________________ $________________per month

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

Second Job with _____________________ $________________ per month

Third Job with ______________________ $________________ per month

Commissions from all jobs $________________ per month

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

Unemployment benefits $________________ per month

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Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI)

$_________________per month

Investment and Rental Income $________________ per month

Annuity payments $________________ per month

Pension or Disability from work or military $________________ per month

Worker’s Compensation $________________ per month

Court-ordered spousal maintenance you receive $________________ per month

Other income____________________________ $________________ per month
Identify Source

Add all of the above. Total monthly income $ ________________ per month

Enter the amount of child support you are court-ordered
to pay for any nonjoint child(ren) $________________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? YES NO

24. Respondent’s Employment

a. Is Respondent employed? YES NO UNKNOWN

b. Is Respondent Self-Employed? YES NO UNKNOWN

c. Is Respondent working at least 40 hours per week? YES NO UNKNOWN

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

st nd
Questions about Jobs 1 Job 2 Job

Is Respondent paid by the hour or hourly salary hourly salary

salaried? Unknown Unknown

What is the average number of hours ________________hours ________________hours

Respondent works per week? Unknown Unknown

How much overtime pay does

Respondent receive per week on $_____________________ $____________________

average? Unknown Unknown

Does Respondent receive bonuses? If Yes, how much did Respondent If Yes, how much did Respondent

Yes No Unknown 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 Gross Income (before taxes and deductions.)

OR

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 Amount Per Month (before deductions/taxes)

Self Employment Income $___________________ (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______________________________ $ ___________________ per month

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

Second job with________________________ $____________________ per month

Commissions from all jobs $____________________ per month

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

Unemployment benefits $____________________ per month

Social Security Retirement, Survivors or Disability Income (RSDI)

(do not include SSI) $____________________ per month

Investment and Rental Income $____________________ per month

Annuity payments $_____________________ per month

Pension or Disability from work or military $_____________________ per month

Worker’s Compensation $_____________________ per month

Court-ordered spousal maintenance received
by Respondent $____________________ per month

Other income____________________________ $____________________ per month
Identify Source

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:

Name the joint children who are covered_____________________________________ Nonjoint children

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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:

Name the joint children who are covered____________________________________ Nonjoint children

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:

Name the joint children who are covered____________________________________ Nonjoint children

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:

Name the joint children who are covered_____________________________________ Nonjoint children

f. If the joint children are without health care coverage, is coverage available for purchase through

Petitioner’s or Respondent’s employer? YES NO The children currently have health

coverage

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? YES NO

Does Respondent own a vehicle? YES NO UNKNOWN

List all vehicles owned by husband or wife together or separately:

Type of Year/Make/ Name(s) on Value Balance Owed Monthly
Vehicle (car,
Model Title Payment
boat, truck etc.)
$ $ $

$ $ $

$ $ $

$ $ $

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.

Has the marital property been divided already to the Petitioners’ satisfaction? YES NO

If NO, Petitioner requests the following marital property:

________________________________________________________________________________

________________________________________________________________________________

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? YES NO

If YES, list Petitioner’s non-marital property:

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? YES NO

Does Respondent have money in banks, savings, cash or investments? YES NO UNKNOWN

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 Type of Account Account # Amount Belongs to:

Institution Last 4 digits only (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 $ OR UNKNOWN.

33. Business Interest

Does Petitioner have an interest in a business? 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? YES NO

Does Respondent own a manufactured home? YES 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. Do Petitioner and Respondent jointly own real property? YES NO

b. 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 NO UNKNOWN

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c. How many properties are owned by you and your spouse in total? None One Two

Three _______

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.

st
1 Mortgage: Amount currently owed $ and name of lender

2nd Mortgage: Amount currently owed $ 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 NO

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:

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 NO UNKNOWN

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

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? YES NO

Does Respondent have debt? YES 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 Money was used Whose Name is on the Account Balance Monthly
to: for: and When was the Debt Owed Payment
Incurred?
Name Date
$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $
Total Debt $ $

38. Name Change

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Does Petitioner want to change his/her name? YES NO If YES, answer (a) through (c)

below:

a. Petitioner’s name should be changed to

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 False

c. Has Petitioner been convicted of a felony? YES NO If YES, answer i. and ii:

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. Dissolving the bonds of matrimony between Petitioner and Respondent to end the marriage.

2. 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 Solely to Respondent OR Jointly to

both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

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Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

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 Solely to Respondent OR Jointly to

both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

Solely to Petitioner OR Solely to Respondent OR Jointly

to both parties.

4. Parenting Time

a. Petitioner’s parenting time shall be: Unsupervised Supervised Reserved

b. Respondent’s parenting time shall be: Unsupervised Supervised 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: The children are with Respondent:
less than 10% of the time less than 10% of the time
10-45% of the time 10-45% of the time
45.1-50% of the time 45.1-50% of the time
more than 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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———————– Page 28———————–

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.

b. Ordering ____________________________(full name) to provide medical dental

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 # Amount Awarded to

(Last 4 digits only)
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 , County of ___________________________,

State of , which has the following legal description: ______________

_______________________________________________________________________________

_______________________________________________________________________________

with the following mortgages and loans to be paid, after the divorce is final, by Petitioner

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Respondent:

st
1 Mortgage: Amount currently owed: $ and name of lender:

2nd Mortgage: Amount currently owed: $ 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 , County of ___________________________,

State of , which has the following legal description: ______________

_______________________________________________________________________________

_______________________________________________________________________________

with the following mortgages and loans to be paid, after the divorce is final, by Petitioner

Respondent:

st
1 Mortgage: Amount currently owed: $ and name of lender:

2nd Mortgage: Amount currently owed: $ 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 3 7 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

DIV802 State ENG Rev 4/09 www.mncourts.gov/forms Page 34 of 34


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