Fill and Sign the Application Temporary Relief Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution with 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. During the marriage, the following child(ren) were born to or adopted by the parties: Child’s Full Name ( first, middle, last ) Date of Birth Lives With Child’s Address (Street Address, City, State, Zip Code) DIV1004 State ENG Rev 1/07 www.mncourts.gov/forms Page 1 of 5 b. 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 ): c. It is in the best interests of the child(ren) that the child(ren) be in the physical custody of the □ wife □ husband □ both parties because ( specifically explain your reasons ) d. 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). These children □ do □ do not live with the wife. e. 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). These children □ do □ do not live with the husband. 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 $ $ / $ $ $ $ $ $ / $ $ $ $ $ $ / $ $ $ $ DIV1004 State ENG Rev 1/07 www.mncourts.gov/forms Page 2 of 5 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 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 t. Home Maintenance u. Child(ren)’s School Needs $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ DIV1004 State ENG Rev 1/07 www.mncourts.gov/forms Page 3 of 5 v. Child(ren)’s Allowances w. Additional info ( explain ): $ $ $ $ $ $ $ $ TOTAL MONTHLY EXPENSES $ $ 7. My gross monthly income is $ from My spouse’s gross monthly income is $ 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. $ per month is a reasonable amount to be paid by me for temporary support for ( number of ) child(ren). b. $ per month is a reasonable amount to be paid to me for temporary support for (number of) child(ren). c. $ per month is a reasonable amount to be paid to me for temporary spousal maintenance. d. Payment should be made on the first (1 st ) and fifteenth (15 th ) of each month starting on (month, day, year) . 9. 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. 10. Additional Material Facts: DIV1004 State ENG Rev 1/07 www.mncourts.gov/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 DIV1004 State ENG Rev 1/07 www.mncourts.gov/forms Page 5 of 5