Fill and Sign the Mn Questionnaire Form

FINANCIAL QUESTIONNAIRE OF NON-CUSTODIAL PARENT RE: ____________________ 1. Provide the following information: a. Full name __________________________________________________________ b. Date of birth ________________________________________________________ c. City and State of Birth ________________________________________________ d. Social security number ________________________________________________ e. Marital status _______________________________________________________ 2. What is the address where you live? _____________________ a. How long have you lived there? _____________________ b. Who do you live with? ________________________________________________ 1) Number of people in your home ___________________________________ 2) Name and relationship of people in your home. _____________________ c. Do you plan to move within the next 90 days? Yes No 1) If yes, so state your address and date of move. _____________________ d. What is your phone number? ___________________________________________ 3. How many years of school did you complete? _____________________ a. List any diplomas or degrees that you have received. _____________________ b. When did you receive the above degrees? _____________________ 4. Are you currently a student? Yes No a. What school do you attend? _____________________ b. What are you studying? _____________________ c. When did you enroll? _____________________ d. Are you full-time or part-time? _____________________ e. Do you attend days or nights? _____________________ f. When will you graduate? _____________________ 5. Were you ever in the armed forces? _____________________ a. What branch of the service? _____________________ b. List dates of active duty. _____________________ 6. Are you employed? Yes No a. What is the name and address of your employer? _____________________ b. What is your telephone number at work? _____________________ c. What is your job title? _____________________ d. How long have you had this job? _____________________ e. How many hours per week do you work? _____________________ f. What is your hourly wage, salary, and rate of pay or schedule of commissions? _____________________ g. How often are you paid? _____________________ h. My gross earnings are $ ____________ per i. I have the following deductions from my pay: Federal Income tax $ ____________ per __________ State Withholding $ ____________ per __________ Social Security (FICA) $ ____________ per __________ Union dues $ ____________ per __________ Medical insurance $ ____________ per __________ Other __________ $ ____________ per __________ - 2 - Other __________ $ ____________ per __________ 7. If you are employed, attach two or more recent check stubs for average pay periods. 8. Attach copies of your state and federal tax returns for the last two (2) years. (If you do not have copies, you may order them from the United States Revenue Service and the state revenue service where you filed your return.) 9. Do you have individual health insurance? Yes No a. What is the name of your insurance company? ____________________________ b. Is health insurance available through your employer? Yes No c. What is the cost to you of any health insurance you currently have? $ ____________ d. How much would it cost you to add dependent health and/or dental insurance? $ ____________ 10. List any expenses that are specifically necessary for the generation of income (e.g. uniforms, tools, etc.) Expense Amount _____________ $ ____________ _____________ $ ____________ _____________ $ ____________ _____________ $ ____________ _____________ $ ____________ 11. My other income is (verification required): a. Public Assistance (AFDC/GA) $ _________ per ________ b. Social security benefits for party or child(ren) $ _________ per ________ c. Unemployment/workers compensation $ _________ per ________ d. Interest income per $ _________ per ________ e. Dividend income $ _________ per ________ f. Gross rental income $ _________ per ________ g. Other income $ _________ per ________ - 3 - 12. Give the following information for every one of your natural or legally adopted children. Use a separate sheet of paper for more than two (2) children. Child's name: __________ Child's date of birth __________ Name of child's other parent __________ Who has legal custody of the child? __________ Where does the child live? __________ Were you married to the child's other parent? Yes No Is there a court order for child support? Yes No What is the monthly amount of the child support order? $ __________ Are you paying the child support? Yes No Are you receiving the child support? Yes No Name the state and county where child support was ordered. __________ The child(ren)'s physical and emotional needs are: (check one) Normal Other (explain) __________ The child(ren)'s special education needs are: (check one) None Other (explain) __________ This child's other financial resources are: (check one) None Other such as your wife's income, social security __________ * * * * * - 4 - Child's name: __________ Child's date of birth __________ Name of child's other parent __________ Who has legal custody of the child? __________ Where does the child live? __________ Were you married to the child's other parent? Yes No Is there a court order for child support? Yes No What is the monthly amount of the child support order? $ __________ Are you paying the child support? Yes No Are you receiving the child support? Yes No Name the state and county where child support was ordered. __________ The child(ren)'s physical and emotional needs are: (check one) Normal Other (explain) __________ The child(ren)'s special education needs are: (check one) None Other (explain) __________ This child's other financial resources are: (check one) None Other such as your wife's income, social security (explain) __________ 13. List all of your significant assets such as cash, checking and savings balances, property, real estate, stocks, bonds, certificates, trust accounts, valuable collections or vehicles of any kind. List anything that is worth more than $1,000. Item Value __________ $ _____________ __________ $ _____________ - 5 - __________ $ _____________ __________ $ _____________ __________ $ _____________ __________ $ _____________ __________ $ _____________ 14. List any public debts such as back taxes, fines and restitution. (Verification/proof required.) Item Amount __________ $ _____________ __________ $ _____________ __________ $ _____________ __________ $ _____________ __________ $ _____________ __________ $ _____________ __________ $ _____________ 15. List all unpaid and uninsured medical expenses. (Verification/proof required.) Service Provider Value __________ __________ $ _____________ __________ __________ $ _____________ __________ __________ $ _____________ __________ __________ $ _____________ __________ __________ $ _____________ __________ __________ $ _____________ __________ __________ $ _____________ 16. List all student loans. (Verification/proof of original loan amount, monthly payment, and balance owed on loan required.) Type of Loan Monthly Payment Original Amount __________ $ _____________ $ _____________ __________ $ _____________ $ _____________ __________ $ _____________ $ _____________ __________ $ _____________ $ _____________ __________ $ _____________ $ _____________ __________ $ _____________ $ _____________ __________ $ _____________ $ _____________ 17. List all other debts and living expenses. Living Expenses (Includes Rent, Food, Utilities, etc.) Type of Expense Average Monthly Cost - 6 - ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ ___________ $ ___________ Regular Payments (Include car payments, insurance, credit cards, etc.) To Whom Monthly Payment Account Balance For What ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ ______ $ _________ $ _________ ________ NOTE: Asterisk (*) any of the above debts and expenses that were reasonably incurred for the necessary support of the child, AND provide a notarized statement of the debts, with supporting documentation, showing goods or services purchased, the recipient of the goods or services purchased, the amount of the original debt, the outstanding balance, the monthly payment, and the number of months until the debt will be fully paid. - 7 - 18. I am currently married to ___________________ a. My spouse works at ___________________ b. My spouse works: (check one) Part-time Full-time Other (explain) c. My spouse earns $ _________ per ___________________ 19. Other information I would like to give: ___________________ 20. Give the name, address and telephone number of your attorney for this matter. ___________________ DATED: _________________ ________________________________ (signature) - 8 -