Fill and Sign the Minnesota Affidavit Support 497312683 Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: In Re the Custody of: Petition To Establish Custody and Parenting Time [Minn. Stat. § 518.156] Petitioner Recognition of Parentage signed [ Minn. Stat. § 257.75, subd. 3] and Respondent 1. I am the Petitioner. My name and address: First Middle Last Street Address Apt. # City State Zip Code 2. The other parent is the Respondent. Respondent’s full name and address: First Middle Last Str e et Address Apt. # City State Zip Code 3. The names and dates of birth of the minor children involved in this action are: Child’s Full Name Date of Birth First Middle Last Month / Day / Year First Middle Last Month / Day / Year CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 1 of 5 4. The children currently live with: □ Me □ Other parent □ Other person (print full name of other parent or person) : __________________________________________________. The address of the children is: ___________________________________ in the City of _________________________, County of ____________________________, State of _______________________, zip code ________________. The children have lived at this address since _______________________ (mo/day/yr). If children have lived less than six months at the above listed address, list dates and locations of where the children have been living for the last six months: 5. Petitioner and Respondent signed a Minnesota Recognition of Parentage (ROP) for the minor children listed above. The Recognition of Parentage has been filed with the Minnesota Department of Health and is a basis for bringing an action to grant custody, parenting time, and/or child support pursuant to Minn. Stat. § 257.75, subd. 3 (2010). (check one) □ Petitioner has included a certified copy of the Recognition of Parentage with this Petition. □ Petitioner requested a certified copy from the Minnesota Department of Health and will file it with the court when Petitioner receives it. 6. A court-appointed guardian or custodian has been appointed for the children. □ No □ Yes – A guardian or custodian has been appointed for the children by court order in Court File No. ________________________ in the State of ___________________________ and the name of the guardian / custodian is _________________________________________________ (Note: Minn. Stat. § 518.156, subd. 2, requires the Petitioner to give written notice of this proceeding to the guardian / custodian.) CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 2 of 5 7. Petitioner’s request for custody and parenting time: a. Legal Custody : Legal custody means having a right to participate in the major decisions regarding the child’s life, including education, religious upbringing and medical treatment. It is in the child’s best interests that legal custody is granted as follows: (check one) □ Joint legal custody to both parents □ Sole legal custody to □ Petitioner □ Respondent b. Physical Custody : Physical custody identifies who will handle the routine daily care and control of the child, and who the child will live with. It is in the child’s best interests that physical custody is granted as follows: (check one) □ Joint physical custody to both parents □ Sole physical custody to □ Petitioner □ Respondent 8. A child protection case involving the children in this case is open: □ YES □ NO If YES , this case is in _______________________ County in the State of _________________, and the Court File Number is _________________________. The child protection worker’s name is . 9. An Order for Protection involving me and the other parent __________________________ (print full name) and/or the children is open: □ YES □ NO. If YES, this case is in _______________________________ County in the State of ____________________________, and the Court File Number is ________________________. A copy of the Order for Protection is included with this Petition. 10. Parenting Time: It is in the child’s best interests that parenting time be granted as follows: □ Grant parenting time to the □ Petitioner □ Respondent CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 3 of 5 □ Grant supervised parenting time to the □ Petitioner □ Respondent □ Deny parenting time to the □ Petitioner □ Respondent 11. Child Support: (check one box) □ There is no existing child support order and Petitioner is asking the court to establish child support in accordance with child support guidelines. □ There is no existing child support order and child support is not being requested in this Petition. □ There is an existing child support order for the children named in this action, located in the County of _________________________ , State of ____________________________, Court File Number ____________________________________. The Petitioner requests that the Court grant the following relief: 1. I am asking the court to grant legal custody as follows: (pick one) □ Joint legal custody to both parents □ Sole legal custody to the □ Petitioner □ Respondent 2. I am asking the court to grant physical custody as follows: (pick one) □ Joint physical custody to both parents □ Sole physical custody to the □ Petitioner □ Respondent 3. I am asking the court to: (pick one) □ Grant parenting time □ Grant supervised parenting time to the □ Petitioner □ Respondent □ Deny parenting time to the □ Petitioner □ Respondent CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 4 of 5 4. Optional – only check box if asking the court for child support. □ I am asking the court to establish child support according to the child support guidelines. Child support includes basic support, medical support, and child care support. 5. Granting such other and further relief as the court may deem just and equitable. DATE: Signature Street Address City/State/Zip Code ( ) Telephone Number E-mail address CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 5 of 5