State of Minnesota District Court
County of Judicial District:
Court File Number:
Assigned Judge:
Case Type:
Dissolution with Children
In Re the Marriage of:
Name of Petitioner (first, middle, last) Petition For Dissolution Of
Marriage With Children
and
Name of Respondent (first, middle, last)
STATE OF MINNESOTA )
) SS
COUNTY OF )
(County where Petition is signed)
1. Information about Petitioner
Full Name: _______________________________________________________________
First Middle Last
Address where you live:
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 Day Year
List all of Petitioner’s former or other names or write “None”:
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First Middle Last
First Middle Last
Petitioner’s social security number is listed on Confidential Form 11.1 and submitted along
with the Petition.
2. Information about Respondent
Full Name:
First Middle Last
Address:
Street Address Apt. No.
City County State Zip Code
Respondent'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 of
_______________________________, State of __________________________, Country
of
4. 180 Day Requirement
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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
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
5 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 , why are you living together at this time?
8. Other Proceedings
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a. Has a separate court case for marriage dissolution, legal separation, custody, paternity 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 or outcome of the case is:
Open Closed I do not know
b. Has a County started a Support case involving the Petitioner and the Respondent or their
children? YES NO If YES, the case was started in ________________________
County in the State of and the Court file number is
.
A copy of the Support Order is submitted with the Petition,
or the case is Dismissed, or Pending.
9. Protection or Harassment Order
a. 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 the child(ren) 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.
b. Does the Order for Protection include an order to pay child support? YES NO
10. Child Protection Court Case
6 Is a child protection case involving Petitioner and Respondent’s child(ren) taking place in
Minnesota or another state? YES NO
7 If YES , the case is in County in the State of __________________ and
the Court file number is . The name of the child or
children involved in the child protection case is:
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11. Children Petitioner and Respondent Have Together (Joint Children)
“Child” means a living person under age 18, or under age 20 and still in high school.
a. Are there any children born to or adopted by Petitioner and Respondent together, either
before or during the marriage? YES NO If YES,
Full Name of Child Date of
Birth Age Child Currently Lives With
Petitioner Respondent
Both parents
OR
( write in name)
Petitioner Respondent
Both parents
OR
______________________________
( write in name)
Petitioner Respondent
Both parents
OR
______________________________
( write in name)
Petitioner Respondent
Both parents
OR
( write in name)
Petitioner Respondent
Both parents
OR
( write in name)
The social security number of the child(ren) is/are listed on Confidential Form 11.1 and is
submitted along with the Petition.
If a child is living with someone other than a parent, write the child's address below:
Address: _______________________________________________________________
Street Address Apt. No.
City County State Zip Code
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b. Has each child born to or adopted by Petitioner and Respondent together lived in
Minnesota for the past six (6) months? YES NO
If NO , name the child or children, name the State(s) the child has lived in during the past 6
months, and the dates the child lived in each state:
12. Adult Dependent Children
Support can be ordered for a joint child over age 18 who cannot support him/herself because of a physical or
mental condition.
Is there an adult joint child born to or adopted by Petitioner and Respondent who is not able
to support himself or herself because of a physical or mental condition? YES NO
If YES , the full name, date of birth and age of each adult dependent is:
Full Name of Dependent Date of Birth Age
The social security number of the adult dependent child(ren) is / are listed on Confidential
Information Form 11.1 and submitted along with the Petition.
13. Pregnancy
a. Is Petitioner pregnant? YES NO
b. If Petitioner is pregnant answer (i) and (ii):
(i) The date the baby is due is
Month Day Year
(ii) Do Petitioner and Respondent agree that the spouse is the biological father of the
unborn child? YES NO
If NO, Petitioner Respondent claims husband is not the biological father of
the child, and P etitioner asks the Court to issue a separate order setting a hearing date
for after the birth of the child to determine Paternity, unless appropriate Recognition
of Parentage documents are signed by husband, wife and the biological father after
the birth of the child.
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c. Is Respondent pregnant? YES NO
d. If Respondent is pregnant answer (i) and (ii):
(i) The date the baby is due is
Month Day Year
(ii) Do Petitioner and Respondent agree that the spouse is the biological father of the
unborn child? YES NO
If NO, Petitioner Respondent claims husband is not the biological father of
the child, and P etitioner asks the Court to issue a separate order setting a hearing date
for after the birth of the child to determine Paternity, unless appropriate Recognition
of Parentage documents are signed by husband, wife and the biological father after
the birth of the child.
14. Petitioner’s Children from Other Relationship (Non-Joint Children)
a. Does Petitioner have minor child(ren) born prior to the marriage from another marriage
or relationship?
YES NO
If YES , the full name, date of birth and age of each child born prior to the marriage is:
Full Name of Child
and Age Date of
Birth Does Child Live
with Petitioner? Is Petitioner Court-
Ordered to pay Child
Support for this Child?
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
b. Has Petitioner given birth, since marrying Respondent, to a minor child who is not a
child of the Respondent? YES NO
If YES , answer (i) , (ii), (iii) and ( iv):
(i) List the full name, date of birth and age of each child born to Petitioner since
marrying Respondent, who is not a child of the Respondent :
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Full Name of Child
and Age Date of
Birth Does Child Live
with Petitioner? Is Petitioner Court-
Ordered to pay Child
Support for this Child?
YES NO YES NO
YES NO YES NO
(ii) Is there a Court Order naming someone other than the Respondent as the father of
the child(ren) listed in (i) above? YES NO
If YES , attach a copy of the Order. The Order is for: _______________________
Full Name of Child(ren)
(iii) Have the Petitioner and biological Father signed a Minnesota Recognition of
Parentage for any of the children listed in (i) above? YES NO
(iv) Has the Respondent signed the “ Husband’s Non-Paternity Statement ” for any of
the children listed at (i) above? YES NO
If YES , state the name of the child: and
submit a copy of the "Husband's Non-Paternity Statement."
If NO, why not?
15. Respondent’s Children from Other Relationship (Non-Joint Children)
a. Does Respondent have minor child(ren) born prior to the marriage from another
marriage or relationship? YES NO UNKNOWN
If YES , the full name, date of birth and age of each child born prior to the marriage is:
Full Name of Child
and Age Date of
Birth Does Child Live
with
Respondent? Is Respondent Court-
Ordered to pay Child
Support for this Child?
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
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b. Has Respondent given birth, since marrying Petitioner, to a minor child who is not a
child of the Petitioner? YES NO
If YES , answer (i) , (ii), (iii) and ( iv):
(i) List the full name, date of birth and age of each child born to Respondent since
marrying Petitioner, who is not a child of the Petitioner:
Full Name of Child
and Age Date of
Birth Does Child Live
with
Respondent? Is Respondent Court-
Ordered to pay Child
Support for this Child?
YES NO YES NO
YES NO YES NO
(ii) Is there a Court Order naming someone other than the Petitioner as the father of
the child(ren) listed in (i) above? YES NO
If YES , attach a copy of the Order. The Order is for: _______________________
Full Name of Child(ren)
(iii) Have the Respondent and biological Father signed a Minnesota Recognition of
Parentage for any of the children listed in (i) above? YES NO
If YES , state the full name of the child: and
submit a copy of the Recognition of Parentage.
If NO , why not?
(iv) Has the Petitioner signed the “ Husband’s Non-Paternity Statement ” for any of the
children listed at (i) above? YES NO
If YES , state the name of the child: and
submit a copy of the "Husband's Non-Paternity Statement."
If NO, why not?
16. Custody
It is in the child’s best interests that legal custody be granted as follows: (check one)
Joint legal custody to both parents
Sole legal custody to Petitioner Respondent
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It is in the child’s best interests that physical custody be granted as follows: (check one)
Joint physical custody to both parents
Sole physical custody to Petitioner Respondent
17. Parenting Time
Petitioner's parenting time with the joint children should be: (check one)
unsupervised supervised reserved
Respondent's parenting time with the joint children should be: (check one)
unsupervised supervised reserved
If parenting time is unsupervised for both parents, skip to Question 18.
For supervised parenting time answer a. and b. For reserved parenting time, answer c.
a. Explain how unsupervised parenting time is likely to endanger the child's physical or
emotional health or impair the child's emotional development:
b. State who should supervise parenting time, and if there
is a cost involved, who should pay the cost, and any other important details:
c. Explain why parenting time should be reserved:
18. Public Assistance from State of Minnesota
If either party is receiving public assistance from the State of Minnesota 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.
a. Does Petitioner receive public assistance from the State of Minnesota?
YES NO
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If YES, the assistance is from __________________ County. (Check all that apply):
MFIP in the amount of $___________per month
Tribal TANF in the amount of $__________per month
General Assistance in the amount of $___________per month
Child Care Assistance MinnesotaCare Medical Assistance
b. Does Respondent receive public assistance from the State of Minnesota?
YES NO UNKNOWN
If YES , the assistance is from __________________ County. (Check all that apply):
MFIP in the amount of $___________per month
Tribal TANF in the amount of $__________per month
General Assistance in the amount of $___________per month
Child Care Assistance MinnesotaCare Medical Assistance
c. Do the joint children of the parties receive public assistance from the State of
Minnesota?
YES NO UNKNOWN
If YES , the assistance is from __________________ County. (Check all that apply):
MFIP Medical Assistance Tribal TANF MinnesotaCare
IV-E Foster Care
19. 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. Does Petitioner receive Supplemental Security Income (SSI)? NO YES in the
amount of $___________ per month.
b. Does Respondent receive Supplemental Security Income (SSI)? NO YES in
the amount of $___________ per month.
c. Do any of the joint children of the parties receive Supplemental Security Income (SSI)?
NO YES in the amount of $___________per month. What is the name of the
child receiving SSI?______________________________________________________
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20. School
Is Petitioner currently enrolled in school? YES NO If Yes:
a. The name of the school is
b. The type of school is High School College Vocational Other
c. The type of degree expected is ____________________________and the expected
graduation date is __________________________.
Is Respondent currently enrolled in school? YES NO UNKNOWN If Yes:
a. The name of the school is
b. The type of school is High School College Vocational Other
c. The type of degree expected is____________________________and the expected
graduation date is __________________________.
21. Petitioner’s Employment
a. Is Petitioner employed? YES NO
b. Is Petitioner Self-Employed? YES NO
c. Is Petitioner working at least 40 hours per week? YES NO
If you are unemployed or working less than 40 hours/week, answer these questions:
i. Explain why you are not working or why you work less than 40 hours/week.
ii. What is your past work experience (type of jobs, hours, pay, length of time at the
job) and what are your professional qualifications or licenses?
d. Current Employment: (If Petitioner has more than two jobs at this time, use an attachment for the
additional jobs.)
_____________________________________________________________________
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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 Employer (If Self-Employed, list name and business address)
_____________________________________________________________________
Employer’s Street Address
_____________________________________________________________________
City State Zip Code
Questions about Current
Jobs 1 st
Job 2 nd
Job
Are you paid by the hour or do
you have a salary? hourly salary hourly salary
What is the average number of
hours you work per week? ________________hours ________________hours
How much overtime pay do
you receive per week on
average? $_____________________ $____________________
Do you receive bonuses?
Yes No If Yes, how much did you receive
in bonuses last year?
$_____________
How much do you expect to
receive this year? $___________ If Yes, how much did you receive
in bonuses last year?
$_____________
How much do you expect to
receive this year? $___________
22. Petitioner’s Income
NOTE: There is a separate form called "Financial Affidavit" which you must fill out, serve
on your spouse, and file with the court at the time you file this Petition. You must include
proof of your income with the Financial Affidavit.
If you do not have income in a category, enter zero (0). Do not list public assistance benefits as
income (e.g. MFIP, GA, SSI).
Source of Income Amount Per Month (or zero) before
deductions/taxes
Self Employment Income $________________ per
month
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Self Employment income means gross receipts minus costs of goods sold
minus ordinary and necessary business expenses. Include Schedule "C"
from last year's tax return to this Petition.
Job with __________________________ $________________per month
Your monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)
Second Job with _____________________ $________________per month
Third Job with ______________________ $________________per month
Commissions from all jobs $________________ per month
Divide the total amount you expect this year by 12 to get a monthly average
Unemployment benefits $________________ per month
Social Security Retirement, Survivors or Disability
Income (RSDI) (do not include SSI) $________________ per month
Investment and Rental Income $________________ per month
Annuity payments $________________ per month
Pension or Disability from work or military $________________ per month
Worker's Compensation $________________ per month
Court-ordered spousal maintenance you receive $________________ per month
Other income____________________________ $________________ per month
Identify Source
Add all of the above. Total monthly income $________________ per month
Enter the amount of child support you are court-ordered
to pay for any nonjoint child(ren) $________________per month
Enter the amount of spousal maintenance you are court-ordered
to pay to your current or former spouse $________________per month
Enter the amount of Social Security or Veteran's Benefits provided to a joint child
because of your retirement, disability, or other eligibility
$________________ per month
If you entered an amount, which parent receives the payment for the child?
Petitioner Respondent
23. Living Expenses for the Family
a. Petitioner and Respondent and our children are still living together. Our current
monthly living expenses for our family total $ .
OR
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b. Petitioner and Respondent are living separately. Our monthly family living expenses
before we separated totaled $ . At this time, Petitioner's separate
monthly living expenses total $____________, and Respondent's monthly living expenses
total $______________or are unknown to Petitioner. Of the total current monthly
living expense for Petitioner, what dollar amount is for expenses just for the children that
live with Petitioner? $_________________. Of the total current monthly living expenses
for Respondent, $___________is for expenses just for the children that live with
Respondent, or this is UNKNOWN.
24. Expenses for Special Needs for the Children
a. Is there a child of the parties who has special needs and extraordinary medical expenses?
YES NO If Yes,
Name of child with special needs:
Describe the needs:
b. Does Petitioner’s monthly living expense (stated at #23) include the special needs
expenses for the child? YES NO
c. Does Respondent’s monthly living expense (stated at #23) include the special needs
expenses for the child? YES NO
25. Respondent’s Employment
a. Is Respondent employed? YES NO UNKNOWN
b. Is Respondent Self-Employed? YES NO UNKNOWN
c. Is Respondent working at least 40 hours per week? YES NO UNKNOWN
If Respondent is unemployed or works less than 40 hours/week, answer these
questions:
i. Explain why Respondent is not working or why Respondent works less than 40
hours/week
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ii. What is Respondent's past work experience (type of jobs, hours, pay, length of time
at the job) and professional qualifications or licenses?
d. Current Employment: (If Respondent has more than two jobs at this time, use an attachment for the
additional jobs.)
______________________________________________________________________
Name of Respondent’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
Questions about Jobs 1 st
Job 2 nd
Job
Is Respondent paid by the hour
or salaried? hourly salary
Unknown hourly salary
Unknown
What is the average number of
hours Respondent works per
week? ________________hours
Unknown ________________hours
Unknown
How much overtime pay does
Respondent receive per week
on average? $_____________________
Unknown $____________________
Unknown
Does Respondent receive
bonuses?
Yes No Unknown If Yes, how much did Respondent
receive in bonuses last year?
$___________
How much does Respondent
expect to receive this year?
$___________ If Yes, how much did Respondent
receive in bonuses last year?
$_________
How much does Respondent
expect to receive this year?
$___________
26. Respondent’s Income
Petitioner has no information about Respondent's income
OR
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Petitioner does not have detailed 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.
If Respondent has no income in a category, enter zero (0). Do not list public assistance benefits as
income (e.g. MFIP, GA, SSI).
Respondent's Source of Income Amount Per Month (or zero) before deductions/taxes
Self Employment Income $_________________per month
Self Employment Income means gross receipts minus costs of goods sold minus ordinary and
necessary business expenses. A ttach Schedule C from last year's tax return to this Petition, if available.
Job with______________________________ $_________________ per month
Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)
Second job with________________________ $_________________ per month
Commissions from all jobs $_________________ per month
Divide the total amount expected this year by 12 to get a monthly average
Unemployment benefits $_________________ per month
Social Security Retirement, Survivors or Disability
Income (RSDI) (do not include SSI) $_________________ per month
Investment and Rental Income $_________________ per month
Annuity payments $_________________ per month
Pension or Disability from work or military $_________________ per month
Worker's Compensation $_________________ per month
Court-ordered spousal maintenance received
by Respondent $_________________ per month
Other income____________________________ $_________________ per month
Identify Source
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Add all of the above. Total monthly income $ ________________ per month
Enter the amount of child support Respondent is court-ordered
to pay for any nonjoint child(ren) $_________________ per month
Enter the amount of spousal maintenance Respondent is court-ordered
to pay to a current or former spouse $________________ per month
Enter the amount of Social Security or Veteran's Benefits provided to a joint child because
of Respondent's
retirement, disability, or other eligibility
$_________________ per month
If you entered an amount, which parent receives the payment for the child?
Petitioner Respondent
27. Child Care Costs
Are there child care costs for the joint children because of work or school ? YES NO
If YES, submit with this Petition a receipt or signed letter from the child care provider
showing the cost of child care, and answer (a) (b) and (c):
8 a. How many of the joint children need child care? One Two Three _________
9 b. How much does the daycare center(s) or babysitter charge per month? $
(If you pay by the week, multiply the weekly charge by 4.33 to get the charge per month. If costs
vary during the year, use the total yearly costs and divide by 12.)
10 c. Who pays the child care costs?
11 Petitioner pays $ per month
12 Respondent pays $ per month
13 The County pays $ per month through a subsidy or child
care assistance.
14 d. If the County pays, who applied for the child care assistance?
15 Petitioner Respondent There is no county assistance
16
28. Health Care Coverage
a. Minnesota Care and Medical Assistance are available from the State of Minnesota for
people who qualify. Who receives Minnesota Care or Medical Assistance?
Petitioner Respondent Joint Children No one
b. Does Petitioner currently have medical insurance? (other than MN Care or Medical
Assistance)
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Yes No. If no, skip to c.
i. Where does Petitioner get the medical insurance?
through his/her employment
buys private medical insurance
ii. How much does the medical insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
iii. Who is currently covered by this medical insurance?
Petitioner Respondent All the Joint Children Some of the joint
children: Name the joint children who are covered_____________________________________
Nonjoint children
c. Does Petitioner have dental insurance? (other than MN Care or Medical Assistance)
Yes No. If no, skip to d.
i. Where does Petitioner get the dental insurance?
through his/her employment
buys private dental insurance
ii. How much does the dental insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
Dental is included in the medical insurance costs.
iii. Who is currently covered by this dental insurance?
Petitioner Respondent All the joint children Some of the joint
children: Name the joint children who are covered____________________________________
Nonjoint children
d. Does Respondent have medical insurance? (other than MN Care or Medical Assistance)
Yes No Unknown. If No/ Unknown, skip to e.
i. Where does Respondent get the medical insurance?
through his/her employment
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buys private medical insurance
ii. How much does the medical insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
iii. Who is currently covered by this medical insurance?
Petitioner Respondent All the joint children Some of the joint
children: Name the joint children who are
covered____________________________________
Nonjoint children
e. Does Respondent have dental insurance? (other than MN Care or Medical Assistance)
Yes No Unknown If No/ Unknown skip to f.
i. Where does Respondent get the dental insurance?
through his/her employment
buys private dental insurance
ii. How much does the dental insurance cost?
$____________per month for single coverage
$____________per month for single plus spouse (if this is offered)
$____________per month for family coverage
Or, Dental is included in the medical insurance costs.
iii. Who is currently covered by this dental insurance?
Petitioner Respondent All the joint children Some of the joint
children: Name the joint children who are
covered_____________________________________
Nonjoint children
f. If the joint children are without health care coverage, is coverage available for purchase
through Petitioner's or Respondent's employer? YES NO The children
currently have health coverage
29. Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.
Check only one box:
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Petitioner and Respondent can each pay their own living expenses and do not need
spousal maintenance at this time, or in the future.
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)
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.
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 monthly
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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30. Vehicles
Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles
etc. owned by Petitioner or Respondent together or separately, including 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 or Respondent together or separately:
Type of
Vehicle (car,
boat, truck etc.) Year/Make/
Model Name(s) on
Title Value Balance
Owed Monthly
Payment
$ $ $
$ $ $
$ $ $
$ $ $
31. 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 already to the Petitioner’s satisfaction?
YES NO
If NO , Petitioner requests the following marital property:
_________________________________________________________________________
_________________________________________________________________________
32. 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:
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b. Does Respondent have non-marital property? YES NO UNKNOWN
If YES, list Respondent’s non-marital property:
__________________________________________________________________
33. 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,
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, account holder name(s), and account
numbers.
Do not include Pension or Employer-Funded Retirement Accounts, which are listed at
#37.
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 $ .
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Respondent has cash in the amount of $ OR UNKNOWN
34. B usiness 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
_________________________________________________________________________
and the value is $________________. How did you arrive at this value?
35. 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 separately,
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? $
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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 36.
36. Real Property - Land, Buildings, Contracts for Deed
All real property now owned by Petitioner or Respondent together or separately must 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
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. Staple the
additional sheets to this Petition, and label each sheet "Attachment to Petition of
____________________(your name)"
Real Property Information
1. Real Estate belongs to: (List full names of all 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 ______________________________
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City______________________________ State_____________ Zip code______________
The property is in _____________________________________County.
4. Purchase date_________________(month , day, year) and purchase price:$
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
37. 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, account holder name, 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:______________________________________________
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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:
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, account holder name, 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:
38. Debts
Does Petitioner have debt? YES NO
Does Respondent have debt? YES NO UNKNOWN
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If YES, list debts in your name, 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 $ $
39. Name Change
Does Petitioner want to change his/her name? YES NO If YES, answer (a) through
(c) below:
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:
_____________________________________________________________________
_____________________________________________________________________
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b. Petitioner has no intent to defraud or mislead anyone by changing his/her name:
True False
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”.
40. 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. Legal Custody : Legal Custody means which p
