Fill and Sign the Minnesota Support Child Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Responsive Affidavit in Support of Establishing Custody and Parenting TimePetitioner and Respondent My name is and I state that: 1. I am the Respondent in this case, and I make this Affidavit in support of my response to the other party’s request to establish custody and parenting time. 2. A child protection case involving any or all of the children in this case is open:  YES  NO If YES, this case is in County in the State of , and the case file number is . The child protection worker’s name is . 3. An Order for Protection involving me and the Petitioner and/or the children exists:  YES  NO If YES, this case is in County in the State of , and the case file number is . A copy of the Order for Protection is included with this Affidavit . 4. The children currently live with:  Me  Other parent  Other person ( print full name ): . I am the children’s: ( list relationship ) . CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 1 of 11 The other party is the children’s:( list relationship ) . The address of the children is: in the City of , State of , Zip Code . The children have lived at this address since: (mo/day/yr) . 5. I want the court to grant legal custody of the children ( check one ):  a. Jointly to both me and the other party because  b. Solely to (check one):  Me  Other party because 6. I want the court to grant physical custody of the children ( check one ):  a. Jointly to both me and the other party, with the children living with me at the following times: and the children living with the other party at the following times:  b. Solely to (check one):  Me  Other party 7. I believe that my request for physical custody is in the best interests of the children because ( list your reasons why, be specific ) CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 2 of 11 8. I want to respond to things the other party stated at paragraph 4 of their Affidavit in Support of Establishing Custody and Parenting Time. My response is: 9. Parenting Time. I want the parenting time schedule as follows: [Use the space below to explain clearly when each parent will have the children. State the time (o’clock) when the children will transfer from one parent to the other. If you want the order to say who will pick up and drop off the children, or where the transfer of the children should take place, include that under “Other.”] Regular Parenting Time Schedule: Monday through Friday: Weekends: Summer (if you want a schedule that is different than the regular one): Telephone contact with the children:  Unlimited or  Only at certain times as follows: (describe the days and times when the parent and children may have telephone contact) Exceptions to the Regular Schedule (You can have a different schedule for holidays, school release days, and birthdays.) Do you want a different schedule for school release days or breaks during the school year? CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 3 of 11 Yes No School release days or breaks during the school year: Any school relase day schedule will override the regular parenting schedule. Do you want a different schedule for birthdays (child’s or parents’ birthdays)? Yes No Birthdays (child’s birthdays, parents’ birthdays): Do you want a different schedule for holidays? Yes No State the specific holidays and the schedule for each holiday you list here: Any birthday or holiday schedule will override the regular and school release parenting schedule. Other: I believe that this schedule is in the best interests of the children because 10. Overnights . Based on the schedule above, how many overnights will the children have with each parent each year (the number must add up to 365)? Note: if parenting time is equal, use 182.5 overnights for each parent. Number of overnights with Petitioner: Number of overnights with Respondent: CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 4 of 11 11. I want to respond to the other party’s requests for parenting time. My response is: 12. I want the court to order to order supervised parenting time:  YES  NO If yes, I believe supervised parenting time is in the best interest of the children because: 13. The other party has asked the court to order supervised parenting time for me and the children:  YES  NO If yes, I object. My response to Petitioner’s statements in paragraph 5 of their Affidavit in Support of Establishing Custody and Parenting Time is: 14. I want the court to order that the children be transferred at a visitation exchange center if one is located in the area, and for both parties to follow all rules of the visitation exchange center:  YES  NO If YES, this is the best interests of the children because If NO, the children should be transferred at: because Note : The visitation exchange center may require the parties to pay a fee for each exchange. CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 5 of 11 15. Child Support. a. Has the other party asked the court to establish child support?  YES  NO b. Are you asking the court to establish child support?  YES  NO Only answer questions #15 - #35 if the answer to either of these questions is YES. If the answer to both questions is NO, then skip to #36. Current Information About Me 16. I am currently (check all that apply) :  Married  Separated  Divorced  Living with a companion  Single 17. I am currently (check one)  employed  unemployed (if employed, answer the following) : a. Employer: b. Address: c. Work telephone number: d. Occupation /Type of work: e. Length of employment: f. Supervisor: g. Gross Pay: $_________________ This  does  does not include overtime pay. h. Paid:  Weekly  Every other week  Twice a month  Monthly i. Previously employed by for ___________ years prior to the above employment. 18. I have the following additional sources of income: Commissions $ Pension Payments $ Annuity Payments $ Unemployment Benefits $ Military / Naval Retirement $ Workers’ Compensation $ Spousal Maintenance Received $ Disability Payments $ Self-Employment $ Other $ 19. I receive (check only if it applies)  MFIP  Medical Assistance  MinnesotaCare  General Assistance  SSI  Child Care Assistance CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 6 of 11 20. The joint children currently receives monthly social security or veteran’s benefits in the amount of $ based on  my disability  the other parent’s disability and is paid to  me  other parent. 21. I am court ordered to pay monthly spousal maintenance. ( check one)  YES  NO If yes, how much? 22. I support the following nonjoint children: Child's Name Date of Birth Relationship Child support Living in monthly amount my home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No (If ordered to pay child support for any child listed above, provide copies of court orders) 23. My monthly expenses at the present time are as follows (if remarried, include total of household expenses): Monthly Payment at Present Time a.  House payment or  Rent $ b. Real Estate Taxes, if not included in (a) $ c. Association Dues or Lot Rent (for property) $ d. Insurance: Homeowners, if not included in (a) $ Car $ Life $ e. Utilities: (Average Monthly Amount) Gas $ Electricity $ Telephone / Cell Phone $ Water and garbage $ Cable TV $ f. Food $ g. Clothing $ h. Laundry/dry cleaning $ i. Personal allowances and incidentals $ j. Magazine and newspapers $ CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 7 of 11 k. Uninsured / unreimbursed medical expenses $ l. Uninsured / unreimbursed dental expenses $ m. Child care expenses $ n. Transportation expenses: Car payment $ License $ Gasoline $ Repairs $ o. Recreation/Entertainment $ p. Children's needs (sports/school/hobbies) $ q. Allowances $ r. Other (list) $ s. Charge accounts and loans (list): Name of Account Balance Owed 1. $ ____________________ 2. $ ____________________ 3. $ ____________________ 4. $ ____________________ 5. $ ____________________ TOTAL MONTHLY EXPENSES: $ 24. The following people help me pay my current monthly expenses listed in question 22:  Spouse  Companion  Roommate(s)  Relatives  No One 25. The value of the property I currently own by myself or with someone else is: Home $____________________ Household goods $____________________ Purchase price of my home $_________________ Balanced owed on my home $____________________ Other real estate $____________________ Checking/savings $____________________ Automobiles $____________________ (year and make) Recreational vehicles $____________________ (year and make) Personal property $____________________ Stocks/bonds/etc. $____________________ Current Information About Other Parent 26. To the best of my knowledge, the other parent is currently: (check one)  employed  unemployed (if employed, answer the following) : a. Employer: b. Address: c. Work telephone number: CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 8 of 11 d. Occupation / Type of work: e. Length of employment: f. Supervisor: g. Gross Pay: $_________________ This  does  does not include overtime pay. h. Paid:  Weekly  Every other week  Twice a month  Monthly  Unknown i. Previously employed by for ___________ years prior to the above employment. 27. To the best of my knowledge, the other parent has the following additional sources of income: Commissions $ Pension Payments $ Annuity Payments $ Unemployment Benefits $ Military / Naval Retirement $ Workers’ Compensation $ Spousal Maintenance Received $ Disability Payments $ Self-Employment $ Other $ 28. To the best of my knowledge, the other parent receives (check only if it applies)  MFIP  Medical Assistance  MinnesotaCare  General Assistance  SSI  Child Care Assistance 29. To the best of my knowledge, the other parent is ordered to pay spousal maintenance. ( check one)  YES  NO If yes, how much? 30. To the best of my knowledge, the other parent supports the following nonjoint children: Child's Name Date of Birth Relationship Child support Living in monthly amount the home $ Yes / No $ Yes / No $ Yes / No $ Yes / No $ Yes / No Parents Health Care Coverage Information Only answer if you are asking for a change in health care coverage and/or dental coverage for the joint children. 31. About me: (check all that apply)  I am court ordered to carry health care coverage for the joint children  I now have private health care coverage available for the joint children  I do not have or no longer have private health care coverage available for the joint children CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 9 of 11  I cannot afford to pay my proportionate share of health care coverage for the joint children  My proportionate share of health care coverage for the joint children should be changed  I am court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children.  I have private health care coverage and/or dental insurance coverage in place for the following people: Cost of monthly health care coverage for self: $ Cost of monthly health care coverage for dependents: $ Cost of monthly dental insurance for self (if separate coverage from health care coverage): $ Cost of monthly dental insurance for dependents (if separate coverage from health care coverage): $ 32. Currently, there is:  no court order that directs either parent to carry private health care coverage for the joint children.  a court order that directs  me  the other parent to carry private health care coverage for the joint children.  Medical Assistance  MinnesotaCare currently in place for the joint children. 33. About the other parent: (check all that apply)  The other parent is court ordered to carry health care coverage for the joint children  The other parent has private health care coverage available for the joint children  The other parent does not have or no longer has private health care coverage available for the joint children  The other parent is court ordered to maintain health care coverage for other nonjoint children and coverage is in place for other nonjoint children.  The other parent has private health care coverage and/or dental insurance coverage in place for the following people: Cost of monthly health care coverage for self: $ Cost of monthly health care coverage for dependents: $ Cost of monthly dental insurance for self (if separate coverage from health care coverage): $ Cost of monthly dental insurance for dependents (if separate coverage from health care coverage): $ Child Care Obligation Only answer if you are asking for a change in child care support for the joint children. 34.  I am court ordered to pay a proportionate share of child care support and the amount of child care support has changed.  There is no court ordered child care obligation and I have child care expenses. CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 10 of 11 35. If there is an existing court order for monthly child care expenses, list the court ordered amount: $ 36. The current total monthly costs of child care are $ Additional Information. 37. The following is additional information regarding the reasons I am requesting to establish custody and parenting time: I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated : Signature County and State where signed: Name: Address: _______________________ City/State/Zip: Telephone: ( ) E-mail address: CHC203 State ENG Rev 8/18-D www.mncourts.gov/forms Page 11 of 11