Fill and Sign the Application for Temporary Relief Minnesota 497312712 Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution without Children In Re the Marriage of: Name of Petitioner/Plaintiff □ Petitioner’s □ Respondent’s and Application for Temporary Relief Name of Respondent/Defendant STATE OF MINNESOTA ) ) SS COUNTY OF ) (County where Affidavit signed) My name is and I state under oath that I am the ( check one ): □ Petitioner/Plaintiff □ Respondent/Defendant in this case, and in this Application for Temporary Relief , I will be referred to as the: □ Husband □ Wife. I understand that 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 ) . The Wife’s age is years and the Husband’s age is years. 2. The parties have been separated month(s), during which time: □ Wife □ Husband has paid $ to the: □ Wife □ Husband. 3. a. The family home is: □ owned □ rented by the parties. The family home is now occupied by: □ Wife □ Husband □ Both parties. Other person(s) live in the home ( please specify ): b. The wife has minor child(ren) from a previous marriage or relationship. The wife: □ pays □ receives $ per month for the support of the minor child(ren). DIV604 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 1 of 5 c. The husband has minor child(ren) from a previous marriage or relationship. The husband: □ pays □ receives $ per month for the support of the minor child(ren). 4. The parties have the following assets: Description of Asset Wife uses or in wife’s name Husband uses or in Husband’s name Both use or in both names a. Car market value Balance due Year/Make b. Stocks, Bonds, Notes c. Cash and Savings d. Accounts Receivable e. Homestead/Real Estate $ $ / $ $ $ $ $ $ / $ $ $ $ $ $ / $ $ $ $ 5. 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 $ $ $ $ $ $ $ $ $ $ 6. Necessary Monthly Expenses (for you and the child(ren) if the child(ren) live with you): Monthly Expense Wife/Husband Expenses Child(ren) Expenses a. Rent b. Mortgage payment c. Contract for Deed payment d. Homeowner’s insurance e. Real Estate taxes f. Utilities g. Heat $ $ $ $ $ $ $ $ $ $ $ $ $ $ DIV604 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 2 of 5 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. Home Maintenance t. Additional info ( explain ): $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY EXPENSES $ $ 7. Provide the following data for each employer. Attach paycheck stub(s) for the last month, or if available, the last three month(s): Husband Wife a. Name of Employer Type of Employment b. Income: (1) Gross Income per month (monthly income is to be calculated using a 4.3 multiple). (2) Statutory Deductions Federal Income Tax State Income Tax Social Security, FICA, Medicare Pension Deduction Union Dues Dependent Health/Hospitalization Coverage $ $ $ $ $ $ $ $ $ $ $ $ $ $ DIV604 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 3 of 5 Dental Coverage (3) Subtotal Statutory Deductions (4) Net Income (line 1 subtract line 3) (5) Other Pay Deductions (specify) (6) Subtotal Other Deductions (7) Net Take Home Pay (line 4 subtract line 6) c. Tax withholding figures above are based on Married/Single taxpayer status with what number of deductions (for example; M-4, 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/Worker’s Comp. (4) Interest income per (5) Dividend income per (6) Gross rental income (7) Other: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 8. a. $ has been paid on wife’s attorney’s fees and costs. b. $ has been paid on husband’s attorney’s fees and costs. c. $ is reasonable for the: □ Wife’s □ Husband’s attorney’s fees and costs. 9. Additional Material Facts: DIV604 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 4 of 5 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: Sworn/affirmed before me this Address: day of , . City/State/Zip: Telephone: ( ) Notary Public \ Deputy Court Administrator DIV604 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 5 of 5