Fill and Sign the Application for Temporary Relief Minnesota Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF             JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No.             , Petitioner, APPLICATION FOR TEMPORARY RELIEF AND CASE AND ORDER       , Respondent, STATE OF MINNESOTA ) ) SS. COUNTY OF ________ ) __________________ , the Petitioner/Respondent hereinafter called Wife/Husband , being first duly sworn upon oath, respectfully represents to the Court that: 1. The parties were married on __________________ ; the Wife's age is ____ , the Husband's age is ____ . 2. The parties have been separated ____ months, during which the Husband-Wife has paid $ ________ to the Wife-Husband. 3. (a) There are ____ children of the parties, aged ____ , ____ , ____ , ____ , now in the care of the Wife-Husband at ________ . (b) The family home is owned-rented by the parties and is now occupied by the Wife- Husband-both parties and ________ . (c) For the best interests of the minor children, they should be in the temporary custody of the Husband-Wife. (d) The Wife has ____ minor children of a prior marriage. The amount of support received-paid is $ ________ per month. (e) The Husband has ____ minor children of a prior marriage. The amount of support received-paid is $ ________ per month. 4. The assets of the parties include: APPROXIMATE MARKET VALUE AND ENCUMBRANCES Item Wife Husband Jt . Tenancy Encumbrances (a) Cars $ ________ $ ________ $ ________ $ ________ (Year/Make) (b) Stocks, bonds, Notes $ ________ $ ________ $ ________ $ ________ (c) Cash & Savings $ ________ $ ________ $ ________ $ ________ (d) Claims $ ________ $ ________ $ ________ $ ________ (e) Accts Receiv. $ ________ $ ________ $ ________ $ ________ (f) Homestead $ ________ $ ________ $ ________ $ ________ 5. Secured Debts, not listed above (excluding homestead): (a) Creditor 1 ________ 2 ________ 3 ________ 4 ________ (b) Total Outstand. $ ________ $ ________ $ ________ $ ________ (c) Monthly Payment $ ________ $ ________ $ ________ $ ________ (d) Party Obligated ______________________________________ (e) Security Pledged ___________________________________ 6. Necessary Monthly Expenses: Wife/ Child(ren) Husband (if separate) (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 Drycleaning $ ________ ________ (k) Medical and Dental $ ________ ________ (l) Transportation (inc. car payment) $ ________ ________ (m) Car Insurance $ ________ ________ (n) Life Insurance $ ________ ________ (o) Recreation, Entertainment, Travel $ ________ ________ (p) Newspapers and Magazines $ ________ ________ (q) Social and Church Obligations $ ________ ________ (r) Personal Allowances and Incidentals $ ________ ________ (s) Babysitting and Child Care $ ________ ________ (t) Home Maintenance $ ________ ________ (u) Children School Needs and Allowances $ ________ ________ (v) Additional Information ________ $ ________ ________ re: Debts and expenses ________ $ ________ ________ Total $ ________ ________ 2 7. Employment Data: Provide the following data for each employer. Attach prior month's paycheck stub(s) as Exhibit. Husband Wife (a) Name of Employer ________ ________ Type of Employment ________ ________ (b) Income: (1) Gross income per * ________ $ ________ $ ________ (2) Statutory Deductions: Federal Income Tax $ ________ $ ________ State Withholding $ ________ $ ________ Social Security (FICA) $ ________ $ ________ Pension Deduction $ ________ $ ________ Union Dues $ ________ $ ________ Dependent Health/Hosp. Coverage $ ________ $ ________ Dental Coverage $ ________ $ ________ (3)Subtotal - Statutory Deductions $ ________ $ ________ (4) Net Income (line 1 - line 3) $ ________ $ ________ (5) Other Paycheck Deductions: Specify ________ $ ________ $ ________ (6) Subtotal: (Other Deductions) $ ________ $ ________ (7) NET TAKE HOME PAY (line 4 - 6) $ ________ $ ________ (c) Tax withholding figures above are based on Married or Single taxpayer with # of deductions (Example M-4or S-2): (d) Employer reimbursed expenses $ ________ $ ________ Specify ________ $ ________ $ ________ ________ $ ________ $ ________ (e) Other Income: (1) Public Assistance (AFDC/GA) $ ________ $ ________ (2) Social Security benefits for party or child(ren) $ ________ $ ________ (3) Unemployment/Workers Comp. $ ________ $ ________ (4) Interest income per ________ $ ________ $ ________ (5) Dividend income per ________ $ ________ $ ________ (6) Gross Rental income $ ________ $ ________ (7) Other income ________ $ ________ $ ________ 8. (a) $ ________ is a reasonable amount for temporary support for children per month. (b) $ ________ is a reasonable amount for temporary maintenance per month. (c) Payment should be made on. ________________________ 9. (a) $ ________ has been paid on the Wife's attorney fees and costs. (b) $ ________ has been paid on the Husband's attorney fees and costs. (c) $ ________ is reasonable for Wife-Husband's attorney fees and costs. 3 * Monthly income is to be calculated using a 4.3 multiple. 10. Additional Material Facts: _________________________________________________________ WHEREFORE, Petitioner-Respondent prays for an order granting such relief prior to trial as may be just and lawful. Dated: Petitioner/Respondent Subscribed and sworn to before me this _____ day of ____________, 20___. ______________________________ NOTARY PUBLIC 4