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State of Minnesota District Court
County of Judicial District:
Court File Number:
Assigned Judge:
Case Type: Dissolution without Children
In Re the Marriage of:
Name of Petitioner (first, middle, last) Petition For Dissolution Of
Marriage Without Children
a nd
Name of Respondent (first, middle, last)
1. Information about Petitioner
Full Name:
First Middle Last
Address where Petitioner lives:
Street Address Apt. No
City County State Zip Code
Mailing address:
Same as above address OR
Street Address Apt. No.
City County State Zip Code
Date of Birth: ________________________
Month D ay Year
List all of Petitioner’s former or other names or write “None”:
First Middle Last
First Middle Last
Petitioner’s social secur ity number is listed on Confidential Form 11.1 and submitted
along with the Petition.
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2. Information about Respondent
Full Name:
First Middle Last
Address where Respondent lives:
Street Address Apt. No.
City County State Zip Code
Mailing address:
Same as above address OR
Street Address Apt. No.
City County State Zip Code
Re spondent'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
Respondent’s social security number is listed on Confidential Form 11.1 and submitted
along with the Petition.
3. Our Marriage Petitioner and Respondent were married on: (month, day, year)
in the City of , County o f
State of __________________________, Country of .
4. 180 Day Requirement
a. Has Petitioner been living in Minnesota for the past six (6) months?
YES NO
b. Has Respondent been living in Minnesota for the past six (6) months?
YES NO UNKNOWN
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c.
Petitioner and Respondent were married in Minnesota, but neither Petitioner nor
Respondent reside in Minnesota, nor reside in a jurisdiction that will allow us to maintain
an action for dissolution because of the sex or sexual orientation of the Petitioner and
Respondent.
YES NO
5. Armed Forces a. 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
b. 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.
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, Petitioner and Respondent are living together because:
8. Other Proceedings
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Has a separate court case for marriage dissolution, legal separation, 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 of the case is: Open Closed I do not know
9. Protection or Harassment Ord er
Is an Order for Protection or a Harassment/Restraining Order in effect regarding
Petitioner and Respondent?
YES NO If YES: The Order protects:
Petitioner
Respondent and the Order was filed in
County in State on date, and the Court
file number is .
A copy of the Order must be submitted with this Petition.
10. Children “Minor” children are under age 18, or under age 20 but still in high sch ool.
a. Do Petitioner and Respondent have minor children together?
YES NO
(If YES, you are using the wrong form)
b. Do Petitioner and Respondent have any adult dependent children who are not able to
support themselves because of a physical or mental condition?
YES NO (If
you answered YES, you may ask the court to make an order regarding support for the
adult dependent, but you should use the Marriage Dissolution W ith Children forms to do
this.)
c. Has either Petitioner or Respondent given birth during the marriage to a child who is not a child of the other spouse?
YES NO
If you answered NO to c, skip to d. If YES continue below:
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i. Fill in the information for all children born during the marriage who are not
biological children of both spouses.
ii. Is there a court order naming someone other than the spouse as the father of the child(ren) listed in (i)?
YES NO If YES, fill in:
iii. Have the spouse and biological Father signed a Minnesota Recognition of
Parentage (ROP) for any of the children listed in (i) above?
YES NO
If YES, state the full name of the child:
and submit with the Petition a certified copy of the Recognition
of Parentage.
Has a “Husband’s Non -Paternity Statement” for any of the children listed at (i)
above been signed?
YES NO
If YES , state the name of the child : and
submit with the Petition a certified copy of the “Husband’s Non -Paternity
Statement.”
Full Name of Child Date of Birth Age Which Party is Birth Parent?
Full Name of Child Date of Court
Order County/State of Order Court Case No.
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Stop:
For each minor child listed at c.(i.) you must have a court order OR the
Recognition of Parentage and Non-Paternity Statement to use the Dissolution Without
Children forms. Otherwise, use the Marriage Dissolution with Children forms.
d. Is either spouse pregnant? YES NO UNKNOWN (If either spouse is
pregnant you are using the wrong form. Use Marriage Dissolution with Children.)
11. Public Assistance / Medical Assistance
Note: If either party is receiving public assistance from the State of Minnes ota 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. See Minn. Stat. §
518A.44.
a. Petitioner receives public assistance from the State of Minnesota:
YES NO
If YES, the assistance is from __________________ County. (Check all that apply):
MFIP Tribal TANF General Assistance Child Care Assistance
Minneso ta Care Medical Assistance
b. Respondent receives public assistance from the State of Minnesota:
YES NO UNKNOWN
If YES, the assistance is from __________________ County. (Check all that apply):
MFIP Tribal TANF General Assistance Child Care Assistance
Minnesota Care Medical Assistance
12. 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. Petitioner receives Supplemental Security Income (SSI):
NO YES in the
amount of $ per month.
b. Respondent receives Supplemental Security Income (SSI): NO YES in the
amount of $ per month, or
UNKNOWN
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13.
Petitioner’s Employment
a. Is Petitioner employed?
YES NO
b. Is Petitioner Self-Employed?
YES NO
Name and address of Petitioner’s emp loyer. (If Petitioner has more than one job, list the
Name and Address of each employer.)
________________________________________________________________________
Name of Petitioner’s Employer (If Self -Employed, list name and business address)
________________________________________________________________________
Employer’s Street Address
________________________________________________________________________
City State Zip Code
Name of Petitioner’s Em ployer (If Self-Employed, list name and business address)
________________________________________________________________________
Employer’s Street Address
________________________________________________________________________
City State Zip Code
14. Petitioner’s Gross Income
The Income questions ask for monthly income. If you are paid weekly, multiply your wee kly
income by 4.33 to get monthly income. If you are paid every two weeks, multiply by 2.17 to get
monthly income. If you are paid twice a month, multiply by 2.
Sources of Income Amount per month (or zero) before taxes and deductions
Self Employment Income $ per month
If you are self employed, calculate your net monthly revenues as follows: (Annual gross
revenues minus annual ordinary and necessary business expenses) divided by 12 = Net Monthly
Revenue. Also, attach Schedule C from last year’s tax return to this Petition.
Income from all jobs $ per month
Commissions from all jobs $ per month
Unemployment benefits $ per month
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Social Security Retirement, Survivors or
Disability Income (SSDI or RSDI) $ per month
Investments or Rental Income $ per month
Annuity payments $ per month
Pension or Disability from work or milita
ry $ per month
Workers Compensation $ per month
Court-ordered spousal maintenance you receive $ per month
Other ____________________ $ per month
Identify Source
Total gross income $ per month
Does Petitioner receive child support payments?
YES NO If YES, Petitioner
receives child support payments from ____________________________(name(s) of
payor(s)) in the total amount of $_________________per month.
15. Respondent’s Employment
a. Is Respondent employed?
YES NO UNKNOWN
b. Is Respondent Self-Employed?
YES NO UNKNOWN
Name and address of Respondent’s employer. (If Respondent has more than one job, list
the Name and Address of each employer.)
________________________________________________________________________
Name of R espondent’s Employer (If Self -Employed list name and business address)
________________________________________________________________________
Employer’s Street Address
________________________________________________________________________
City State Zip Code
________________________________________________________________________
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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16.
Respondent’s Gross Income
Petitioner has no information about Respondent’s income. OR
Petitioner does not have de tailed 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.)
The Income questions ask for monthly income. If Respondent is paid weekly, mul tiply weekly
income by 4.33 to get monthly income. If Respondent is paid every two weeks, multipl y by 2.17
to get monthly income. If Respondent is paid twice a month, multiply by 2.
Sources of Income Amount per month (or zero) before taxes and deductions
Self Employment Income $ per month
If Respondent is self employed, calculate net monthly revenues as follows: (Annual gross
revenues minus annual ordinary and necessary business expenses) divided by 12 = Net Monthly
Revenue. Also, attach Schedule C from last year’s tax return to this Pet ition, if available.
Income from all jobs $ per month
Commissions from all jobs $ per month
Unemployment benefits $ per month
Social Security Retirement, Survivors or
Disability Income (SSDI or RSDI) $ per month
Annuity payments $ per month
Investments or Rental Income $ per month
Pension or Disability from work or military $ per month
Workers Compensation $ per month
Court-ordered spousal maintenance you receive $ per month
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Other ____________________ $ per month
Identify Source
Total gross income $ per month
17. Health Care Coverage (Health Care Coverage does not include MinnesotaCare or
Medical Assistance.) a. Does Petitioner have insurance coverage through his/her employment?
Medical:
YES NO Dental: YES NO
If YES , this medical insurance covers:
Petitioner Respondent
and this dental insurance covers:
Petitioner Respondent
b. Does Respondent have insurance coverage through his/her employment?
Medical:
YES NO UNKNOWN
Dental:
YES NO UNKNOWN
If YES, this medical insurance covers:
Petitioner Respondent and this dental
insurance covers:
Petitioner Respondent
c. Does Petitioner receive Medical Assistance or Minnesota Care through the State of
Minnesota?
YES NO
d. Does Respondent receive Medical Assistance or Minnesota Care through the State of
Minnesota?
YES NO UNKNOWN
18. 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. OR
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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)
OR
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. OR
Respondent needs spousal maintenance from Petitioner now. Respondent is
years of age, Petitioner and Respondent have been married for years.
Respondent has the following education:
Respondent’s gross monthly income totals $______________. Respondent’s mo nthly
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.
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19. Vehicles
Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain
vehicles etc. owned by the Petitioner and Respondent together or separately, incl uding vehicles
purchased after separation:
Does Petitioner own a vehicle?
YES NO
Does Respondent own a vehicle?
YES NO UNKNOWN
List all vehicles owned by Petitioner and Respondent together or separately:
Type of
Vehicle (car,
boat, truck etc.) Year/Make/
Model Name(s) on
Title Value Balance Owed Monthly
Payment
$ $ $
$ $ $
$ $ $
$ $ $
20. 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 between the Petitioner and Respondent to
Petitioner’s satisfaction?
YES NO
If NO , Petitioner requests the following marital property:
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21. 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 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:
22. 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,
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savings, money market accounts, certificates of deposit, stocks, bonds, stock options,
mutual funds, savings bonds, and Treasury Bills, etc.
Use Confidential Information
Form 11.1 (CON111) to list Financial Institution name and account numbers.
Do not include Pension or Employer-Funded Retirement Accounts, which are listed a t
#26.
Financial
Institution Type of Account Amount Belongs to:
(name on account)
$
$
$
$
$
$
b. List cash not listed at (a):
Petitioner has cash in the amount of $ .
Respondent has cash in the amount of $ OR UNKNOWN.
23. Business Interest
Does Petitioner have an interest in a business?
YES NO
Does Respondent have an interest in a business?
YES NO UNKNOWN
If YES, the name of the business is , the address is
an d the value is $ . How did you arrive at this value?
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24. 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 separat ely,
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 25.
25. Real Property - Land, Buildings, Contracts for Deed All real property now owned by Petitioner or Respondent together or separately m ust 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
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b. Does Petitioner own real property solely in his/her own name or with someone other
than Respondent?
YES NO
c. Does Respondent own real property solely in his/her own name or with someone
other than Petitioner?
YES NO UNKNOWN
d. 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. Submit the additional
sheets along with this Petition, and label each sheet "Attachment to Petition of ____________________ ” (your name).
Real Property Information 1. Real Estate belongs to: (List full names of 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:$
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5. Mortgages or loans: (List all mortgages and loans on the property)
There are no mortgages or loans on this property.
1 st
Mortgage: Amount currently owed $ and name of lender
2 nd
Mortgage: Amount currently owed $ and name of lender
Other mortgages or loans:
6. Current Market Value of this property: $___________________________________
How did you arrive at this value?
7. This property is the homestead: _______Yes _________No
26. Retirement Plans a. Does Petitioner have a retirement account? (IRA, 401(k), 403(b) or other)
YES NO If YES:
The name of the Financial Institution and account number is listed on Confidential
Information Form 11.1 (CON111). The current 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:
i. The name of the plan is:
ii. The employer, union or group providing the plan is:
iii. The date Petitioner began working at the job or joined the union or group plan is:
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iv. The type of plan is: (e.g. defined benefit, defined contribution)
v. 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:
The name of the Financial Institution and account number is listed on Confidential
Information Form 11.1 (CON111). The current 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:
i. The name of the plan is:
ii. The employer, union or group providing the plan is:
iii. The date Respondent began working at the job or joined the union or group plan
is:
iv. The type of plan is: (e.g. defined benefit, defined contribution)
v. The present value of the pension or plan is:
27. Debts
Does Petitioner have debt?
YES NO
Does Respondent have debt?
YES NO UNKNOWN
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If YES, list debts in your nam
e, 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 to: Money was used for: Whose Name is on the Account and When was the Debt Incurred?
Name Date Balance
Owed Monthly
Payment
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Total Debt $ $
28. Name Change
Does Petitioner want to change his/her name?
YES NO If YES, answer (a)
through (c): 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
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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 submitted with this Petition an Affidavit of Service of the Notice
marked Exhibit “A”.
29. 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. Health Care Coverage for the Parties
a. Ordering each party to provide for his or her own medical dental
insurance.
b. Ordering ____________________________(full name) to provide medica l
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.
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3.
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.
4. 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:
5. 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:
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To Respondent:
6. 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:
7. Cash and Accounts
a. Awarding the savings and investments as follows:
Institution Type of Account Amount Awarded to
$
$
$
$
$
$
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b.
Awarding any cash not included in a. above to the party who currently has the cash
OR
Awarding the cash as follows:
8. Business
None
OR
Awarding the parties’ business as follows:__________________________________
________________________________________________________________________
________________________________________________________________________
9 . Manufactured Home
None
OR
Awarding the manufactured home located at :
street addre ss
city state
to
Petitioner Respondent. The debt on the manufactured home owed to:
shall be paid by Petitioner Respondent.
10. Real Property
None
OR
Awarding solely to Petitioner Respondent all right, title, and interest of the
parties in the real property located at:
Street address in the
City of , County of
State of , which has the following legal description:
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with the following mortgages and loans to be paid, after the divorce is final, by
Petitioner Respondent:
1 st
Mortgage: Amount currently owed: $ and name of
lender:
2 nd
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)
11. Additional Real Property
None
OR
Awarding solely to Petitioner Respondent all right, title, and interest of the
parties in the real property located at:
Street address
in the City of , County of
State of , which has the following legal description:
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with the following mortgages and loans to be paid, after the divorce is final, by
Petitioner Respondent:
1 st
Mortgage: Amount currently owed: $ and name of lender:
2 nd
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)
12. Retirement Funds
a. Award ing Petitioner’s pension, profit sharing, retirement plan, I.R.A., or 401(k) or
other retirement fund as follows:
Petitioner has no retirement funds OR
100% to Petitioner OR
Dividing Petitioner's retirement benefits fairly and equitably between the parties as
follows
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b. Awarding Respondent’s pension, profit sharing, retirement plan, I.R.A.
, or 401(k) or
other retirement fund as follows:
Respondent has no retirement funds OR
100% to Respondent OR
Dividing Respondent's retirement benefits fairly and equitably between the parties as
follows
13. 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 #27
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.
14. Name Change
Petitioner is not requesting a name change; OR
Changing Petitioner’ s name to:
First Middle Last
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15.
Other :
16. Ordering such other relief as the Court deems just and equitable.
17. 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.
I declare under penalty of perjury that everything I have stated in this document is true and
correct. Minn. Stat. § 358.116.
DATE: / /
Month Day Year Petitioner’s Signature
Street Address:
City, State:
Zip Code:
Telephone: ( )
E-mail address:
