Fill and Sign the Affidavit of Andrew Johnson Supporting Defendants Motion to Form

- 1 - STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Matter of: Court File No. , Plaintiff,COMPLAINT (parentage alleged AND By mother) , D efe n dan t,* * * * * * * * * * * * * * * * * * P la in tif f, b ein g f ir s t d uly s w orn , a lle g es f o r h er c au se o f a ctio n: I. T he t r u e a n d c o rre ct n am es, a d dre sse s, a n d s o cia l s e cu rity n um bers o f P la in tif f a n d Defe n dan t a re : P la in tif f: _____ _____________________ _____ _____________________ _____ _____________________S SN : _ ___________________ D efe n dan t: _____ _____________________ _____ _____________________ _____ _____________________S SN : _ ___________________ II. P la in tif f i s b ein g r e p re se n te d i n t h ese p ro ceed in gs b y _ ____________________________, of F ir m , A ddre ss 1 , C ity , S ta te Zi p . I II. P la in tif f's d ate o f b ir th i s _ __________________ _, 2 0_ ___, a n d s h e i s __ _____ _____________ ( _ ___) y ears o f a g e. D efe n dan t's d ate o f b ir th i s - 2 - 2__ _____ _____________ , 2 0_ ___, a n d h e i s _ ___________________ ( _ ___) y ears o f a g e. IV . Pla in tif f ( a n d t h e m in or c h ild ) r e sid e(s ) i n t h e C ounty o f _ ___________________, S ta te o f Min neso ta a n d D efe n dan t r e sid es i n t h e C ounty o f _ ___ ________________, S ta te o f M in neso ta . V . On o r a b out t h e _ __ ___ d ay o f _ ____________ _______, 2 0____, i n t h e C ity o f __ _____ _____________ , C ounty o f _ _____________, a n d S ta te o f _ ___________________, Pl a in tif f, _ _______________ ____, a n d D efe n dan t, _ __ _________________, h ad s e x ual in te rc o urs e . V I. P la in tif f, _ ________ ___________, o n t h e _ ___ d ay o f _ ___________________, 2 0____, i n the C ounty o f _ __________ _________, S ta te o f M in neso ta , g av e b ir th ( o ut o f w ed lo ck ) t o a (m ale )(fe m ale ) c h ild , w hic h c h ild h as b een n am ed _ ___ ________________. V II. D efe n dan t, _ ______ _____________, i s t h e f a th er o f s a id c h ild . V III. A ( d ec la ra tio n)(re co gnitio n) o f p are n ta g e, p urs u an t t o M in n. S ta t. '( 2 57.3 4)(2 57.7 5) h as (n ot) b een s ig ned b y ( P la in tif f) ( D efe n dan t) ( th e p artie s). ( D efe n dan t's n am e a p pears o n t h e c h ild 's bir th c ertif ic ate .)( P la in tif f i s a ) ( T he p artie s a re ) f it a n d p ro per c u sto dia n (s ) f o r s a id m in or c h ild , a n d t h e b est in te re sts o f t h e c h ild w ill b e s e rv ed i f ( P la in tif f i s )(th e p artie s a re ) a w ard ed ( s o le )(jo in t) l e g al a n d (P la in tif f i s a w ard ed s o le ) p hysic al c u sto dy. IX . Defe n dan t h as t h e a b ility t o c o ntr ib ute t o t h e s u p port o f s a id m in or c h ild . X . Pla in tif f i n cu rre d h o sp ita l a n d m ed ic al e x pen se s a s a r e su lt o f h er p re g nan cy a n d t h e b ir th o f sa id m in or c h ild . X I. P la in tif f i s e m plo yed a s a _ ________________ ___ b y _ ___________________, l o cate d a t __ _____ _____________ . S he h as g ro ss i n co m e o f $ _ ___________________ p er __ _____ _____________ a n d n et i n co m e o f $ ____________________ p er __ _____ _____________ . D efe n dan t i s e m plo yed a s a _ ___________________ b y __ _____ _____________ , l o cate d a t _ ______________ _____. H e h as g ro ss i n co m e o f $_ _____ ______________ p er _ ___________________ a n d n et i n co m e o f $_ _____ ______________ p er _ ___________________. P la in tif f i s d ep en den t u pon D efe n dan t f o r a c o n tr ib utio n t o h er m ed ic a l a n d c o nfin em en t e x pen se s a n d t o t h e s u pport o f t h e m in or c h ild (re n ) of t h e p artie s. N eith er p arty r e ceiv es p ublic a ssis ta n ce.W HER EFO RE, P la in tif f p ra y s f o r t h e J u dgm en t a n d D ecre e o f t h is C ourt a s f o llo w s: A DJU DIC ATIO N 1. Adju dic atin g D efe n dan t, _ _________________ __, t o b e t h e f a th er o f t h e m in or ch ild , _ __________ _________, b orn _ ________ ___________ c u rre n tly a g e __ _______________ ___ ( _ ___). - 3 - 3 CUST O DY/V IS IT A TIO N 1. Gra n tin g _ ________ ___________ l e g al a n d p hysic al c u sto dy o f s a id m in or c h ild su bje ct t o _ _______ _____'s r ig ht t o ( re aso nab le )(s u perv is e d )(re aso nab le a n d l ib era l) vis ita tio n.2 . Gra n tin g P la in tif f a n d D efe n dan t j o in t l e g al c u sto dy o f s a id m in or c h ild a n d desig natin g _ ______ _____________ a s ( h is )(h er) s o le p hysic al c u sto dia n s u bje ct t o _________________ ___'s r ig ht t o ( re aso nab le ) ( s u perv is e d ) ( re aso nab le a n d l ib era l) vis ita tio n.3 . Gra n tin g P la in tif f a n d D efe n dan t j o in t l e g al a n d p hysic al c u sto dy o f s a id m in or ch ild .4 . Ord erin g s u ch c u sto d y, c are a n d c o ntr o l o f s a id m in or c h ild a s t h e C ourt d eem s i n (his )(h er) b est i n te re st. C H IL D S U PP O RT 1. Ord erin g s u ch s u pport f o r s a id m in or c h ild a s t h e C ourt d eem s j u st, f a ir a n d eq uita b le .2 . Ord erin g _ ________ ___________ t o p ay t o _ __ _________________ a r e aso nab le su m o f m oney f o r t h e s u pport o f s a id m in or c h il d .3. Rese rv in g t h e i s su e o f s u pport f o r s a id m in or c h ild .4. Req uir in g D efe n dan t t o p ay a r e aso nab le s u m o f m oney t o _ ___________________ fo r t h e c o nfin em en t e x pen se s o f P la in tif f a n d s a id m in or c h ild .5. Req uir in g D efe n dan t t o p ay a r e aso nab le p ro po rtio n o f t h e e x pen se s f o r t h e s u pport of s a id m in or c h ild f o r t h e p ast t w o y ears . IN CO M E W IT H HOLD IN G 1. Req uir in g t h at t h e c h ild s u pport p ay m en t b y _ ___________________ t o _________________ ___ b e m ad e b y i n co m e w ith hold in g p urs u an t t o M in n. S ta t. §5 18.6 13. IN SU RANC E 1. Req uir in g t h at ( _ ___ ________________)(b oth p artie s) p ro vid e m ed ic al ( a n d d en ta l) in su ra n ce f o r t h e b en efit o f s a id m in or c h ild i n a j u st a n d e q uita b le m an ner. - 4 - 4 NAM E C H AN G E 1. Ord erin g t h at t h e m in or c h ild 's n am e b e c h an ged f ro m _ ___________________ t o _________________ ___. S U CH O TH ER 1. For s u ch o th er a n d f u rth er r e lie f a s t h e C ourt d eem s j u st, f a ir a n d e q uita b le i n t h e pre m is e s.D ate d : _ ______ __________ ___ F ir m B y _ ________________________ _ ________________________ P rin te d N am e _ ________________________ _ ________________________ _ ________________________ A ddre ss _ ________________________ T ele p hone A tto rn ey f o r _ _____________ - 5 - 5 VER IF IC ATIO N ST A TE O F M IN NESO TA ) ) S S. C O UNTY O F _ ___________ __ ) ___________________ _____, b ein g f ir s t d uly s w orn , u pon o ath d ep ose s a n d s a y s t h at s h e i s t h e Pla in tif f i n t h e a b ove-e n title d a ctio n; t h at s h e h as r e ad t h e f o re g oin g C om pla in t, k now s t h e c o nte n ts th ere o f a n d t h at t h e s a m e i s t r u e a n d c o rre ct, e x cep t a s t o t h ose m atte rs t h ere in s ta te d o n i n fo rm atio n an d b elie f a n d a s t o t h ose m atte rs s h e b elie v es t h em t o b e t r u e. _ _____________________________N am e o f C lie n tP la in tif f D ate d : _ _ _____ _______________ _P la in tif fS ub sc rib ed a n d s w orn t o b efo re m eth is _ __ __ d ay o f _ ________ ___ , 2 0___ .___ ___ _________________________N OTA RY P U BLIC - 6 - 6 ACK NO W LED G M EN T ST A TE O F M IN NESO TA ) ) S S.C O UNTY O F _ __________ ___ ) _________________ ___________, t h e a tto rn ey f o r P la in tif f i n t h e a b ove-c ap tio ned m atte r, an d _ ___________________ ________, P la in tif f h ere in , h ere b y a ck now le d ge t h at p urs u an t t o M in n. St a t. § 549.2 1, c o sts , d is b urs e m en ts , w itn ess f e es a n d r e a so nab le a tto rn ey s' f e es m ay b e a w ard ed t o Defe n dan t i n t h e e v en t P la in tif f i s f o und t o b e a ctin g i n b ad f a ith a n d/o r a sse rtin g a f riv olo us c la im . ___________________________________________________________N am e o f C lie n tP la in tif f S ubsc rib ed a n d s w orn t o b efo re m eth is _ ____ d ay o f _ _______ ______, 2 0_ __. _ ____________________________N ota ry P ublic_ ____________________________A tto rn ey f o r P la in tif f S ubsc rib ed a n d s w orn t o b efo re m eth is _ ____ d ay o f _ _______ ______, 2 0_ __. _ ____________________________N ota ry P ublic