Fill and Sign the Prehearing Document Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution In Re the Marriage of: Name of Petitioner  Petitioner’s  Respondent’s vs. Prehearing Statement Name of Respondent 1. Personal Information Husband Wife a. Full Name _________________________ __________________________ b. Present Mailing Address _________________________ __________________________ _________________________ __________________________ c. Employer Name _________________________ __________________________ d. Employer Street Address _________________________ __________________________ City, State, Zip _________________________ __________________________ e. Birthdate _________________________ __________________________ f. Marriage Date _________________________ g. Separation Date (Different Residences) ____________________________________________ h. Date(s) of Temporary Order(s) (if any) ____________________________________________ i. Minor child(ren) of this marriage or who will be affected by this legal action are: Full Name of Child Date of Birth Age Living With j. Is the wife now pregnant?  NO  YES, the due date is: _________________________ . DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 1 of 8 k. Is the issue of legal or physical custody contested?  NO  YES. If custody is disputed, each party shall submit proposals for custody and parenting time for each child as Exhibit 1A. 2. EMPLOYMENT : Provide the following data for each employer. Attach prior month(s) paycheck stub(s) as Exhibit 2A. Husband Wife a. Name of Employer _________________________ __________________________ Length of Employment _________________________ __________________________ b. Income: (1) Gross Income per Month $ _______________ $ __________________ (Monthly income is to be calculated using a 4.3 multiple) (2) Statutory Deductions: Federal Income Tax $ _______________ $ __________________ State Withholding $ _______________ $ __________________ Social Security (FICA) and Medicare $ _______________ $ __________________ Pension Deduction $ _______________ $ __________________ Union Dues $ _______________ $ __________________ Dependent Health/ Hospitalization Coverage $ _______________ $ __________________ Dental Coverage $ _______________ $ __________________ (3) Subtotal Statutory Deductions $ _______________ $ __________________ (4) Net Income $ _______________ $ __________________ (line 1 subtract line 3) $ _______________ $ __________________ (5) Other Paycheck Deductions (specify) _______________________ $ _______________ $ __________________ _______________________ $ _______________ $ __________________ (6) Subtotal Other Deductions $ _______________ $ __________________ (7) NET TAKE HOME PAY $ _______________ $ __________________ (line 4 subtract line 6) $ _______________ $ __________________ c. Tax withholding figures above are based on Married/Single taxpayer status with what number of deductions? (Example: M-4 or S-2) ________________ ___________________ DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 2 of 8 d. Will your medical and dental insurance coverage be available for your spouse and children after the dissolution?  YES  NO e. Other Income: (1) Public Assistance (AFDC/GA) $ _______________ $ __________________ (2) Social Security Benefits for party or child(ren) $ _______________ $ __________________ (3) Unemployment/Workers Comp. $ _______________ $ __________________ (4) Interest paid per _____________ $ _______________ $ __________________ (5) Dividend paid per ___________ $ _______________ $ __________________ (6) Gross Rental Income $ _______________ $ __________________ (7) Other Income (specify): _____________________________ $ _______________ $ __________________ _____________________________ $ _______________ $ __________________ f. List all employment benefits received, including but not limited to bonuses paid or due, automobile or travel expense reimbursement, other per diem compensation, and memberships paid by the employer: Petitioner: ___________________________________________________________________ ____________________________________________________________________________ Respondent: __________________________________________________________________ ____________________________________________________________________________ 3. CHILD SUPPORT/SPOUSAL MAINTENANCE: a. As a result of a different case, Petitioner ( check one ):  pays  receives ( check one or both ):  child support  maintenance. If an amount is paid or received, the amount paid/received each month for child support is $ and for maintenance is $ according to the Order issued in County, dated and there ( check one ):  is not an arrearage  is an arrearage in the amount of $ . b. As a result of a different case, Respondent ( check one ):  pays  receives ( check one or both ):  child support  maintenance If an amount is paid or received, the amount paid/received each month for child support is $ and for maintenance is $ according to the Order issued in County, dated and there ( check one ):  is not an arrearage  is an arrearage in the amount of $ . c. In this proceeding a temporary order ( check one ):  has not been issued  has been issued and includes an order for: DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 3 of 8 (1)  Child support to be paid by ( check one ):  Petitioner  Respondent in the amount of $ per month and there ( check one ):  is not an arrearage  is an arrearage of $ . (2)  Maintenance to be paid by ( check one ):  Petitioner  Respondent in the amount of $ per month and there ( check one ):  is not an arrearage  is an arrearage of $ . 4. LIVING EXPENSES: List your necessary monthly expenses: a. Rent $ __________________ b. Mortgage Payment $ __________________ c. Contract for Deed Payment $ __________________ d. Homeowner’s Insurance $ __________________ e. Real Estate Taxes $ __________________ f. Utilities $ __________________ g. Heat $ __________________ h. Food $ __________________ i. Clothing $ __________________ j. Laundry and Dry Cleaning $ __________________ k. Medical and Dental $ __________________ l. Transportation (includes $ car payment) $ __________________ m. Car Insurance $ __________________ n. Life Insurance $ __________________ o. Recreation, Entertainment and Travel $ __________________ p. Newspapers and Magazines $ __________________ q. Social and Church Obligation $ __________________ r. Personal Allowances and Incidentals $ __________________ s. Babysitting and Day Care $ __________________ t. Home Maintenance $ __________________ u. Child(ren)’s School Needs/Allowances $ __________________ v. Additional expenses (specify) _________________________ $ __________________ TOTAL MONTHLY EXPENSES: $ __________________ DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 4 of 8 5 . REAL PROPERTY : Provide the following information for real property owned by you and/or your spouse. If more room is needed, attach another sheet of paper labeled as Exhibit 5A. Homestead Other Property a. Date Acquired _____________ $ ________________ b. Purchase Price $ ____________ $ ________________ c. Present Fair Market Value $ ____________ $ ________________ d. First Mortgage Balance $ ___________ $ ________________ e. Second Mortgage Balance or Home Improvement Loan _ $ ____________ $ ________________ f. Net Value $ ____________ $ ________________ g. Monthly Payment (PITI) $ ____________ $ ________________ h. Rental Income, if any $ ____________ $ ________________ i. Title in name(s) of _____________ _________________ 6. PERSONAL PROPERTY: List the fair market value of the following person property: In Name or Possession of Husband Wife Both a. Household contents $ ____________ $ ____________ $ ____________ b. Stocks, Bonds, etc. (list) _________________________ $ ____________ $ ____________ $ ____________ _________________________ $ ____________ $ ____________ $ ____________ c. Checking Accounts (list) _________________________ $ ____________ $ ____________ $ ____________ _________________________ $ ____________ $ ____________ $ ____________ d. Receivables and Claims (list _________________________ $ ____________ $ ____________ $ ____________ _________________________ $ ____________ $ ____________ $ ____________ e. Motor Vehicles (cars, trucks, vans): (1)Make/Model/Year (2)Make/Model/Year (3)Make/Model/Year _____________ _____________ _____________ Market Value $ ____________ $ ____________ $ ____________ DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 5 of 8 Encumbrance $ ____________ $ ____________ $ ____________ Net Value $ ____________ $ ____________ $ ____________ Monthly Payment $ ____________ $ ____________ $ ____________ In possession of _____________ _____________ _____________ f. Boats, Motors, Campers, Snowmobiles, Trailer, etc.: (1)Make/Model/Year (2)Make/Model/Year (3)Make/Model/Year _____________ _____________ _____________ Market Value $ ____________ $ ____________ $ ____________ Encumbrance $ ____________ $ ____________ $ ____________ Net Value $ ____________ $ ____________ $ ____________ Monthly Payment $ ____________ $ ____________ $ ____________ In possession of _____________ _____________ _____________ g. Other (such as power equipment, tools, guns, valuable animals, etc.): (1) Description (2) Description (3) Description Market Value $ ____________ $ ____________ $ ____________ Encumbrance $ ____________ $ ____________ $ ____________ Net Value $ ____________ $ ____________ $ ____________ In possession of _____________ _____________ _____________ 7. NONMARITAL CLAIMS: List all items you claim are your nonmarital property. Items Claimed as Nonmarital Value ____________________________________________________ $ _________________________ ____________________________________________________ $ _________________________ ____________________________________________________ $ _________________________ ____________________________________________________ $ _________________________ 8. LIFE INSURANCE: List all insurance policies owned by you and your spouse. Policy 1 Policy 2 Policy 3 Company _____________ _____________ _____________ Policy Number _____________ _____________ _____________ Type (Whole or Term) _____________ _____________ _____________ Face Amount $ ____________ $ ____________ $ ____________ DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 6 of 8 Cash Value $ ____________ $ ____________ $ ____________ Loan Balance $ ____________ $ ____________ $ ____________ Insured _____________ _____________ _____________ Beneficiary _____________ _____________ _____________ Owner _____________ _____________ _____________ 9. PENSION PLAN AND/OR PROFIT-SHARING PLAN : a. Plans Through Employment: Husband Wife Present Cash Value $ ____________ $ ____________ Vested or Nonvested _____________ _____________ b. Private Plans (IRA, Keogh, SEP, etc.) Present Cash Value $ ____________ $ ____________ c. Deferred Compensation $ ____________ $ ____________ d. Military Pension or Disability $ ____________ $ ____________ 10. DEBTS: List all debts not already listed in paragraphs 4 or 5. If more room is needed, attach a schedule for secured debts labeled as Exhibit 10A and a schedule for unsecured debts labeled as Exhibit 10B. a. Secured Debts Debt 1 Debt 2 Debt 3 Creditor _____________ _____________ _____________ Balance Due $ ____________ $ ____________ $ ____________ When Incurred _____________ _____________ _____________ Party Obligated _____________ _____________ _____________ Reason for Debt _____________ _____________ _____________ Total Secured Debt: Husband$ __________ Wife$ ____________ Joint$ ____________ b. Unsecured Debts Debt 1 Debt 2 Debt 3 Creditor _____________ _____________ _____________ Balance Due $ ____________ $ ____________ $ When Incurred _____________ _____________ _____________ Party Obligated _____________ _____________ _____________ Reason for Debt _____________ _____________ _____________ DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 7 of 8 Total Unsecured Debt: Husband$ __________ Wife$ ____________ Joint$ ____________ The statements made by me in this Prehearing Statement are true and correct to the best of my knowledge. DATED:________________________ ___________________________________________ Signature of  Petitioner  Respondent ___________________________________________ Signature of Attorney (if any) Attorney Name: ______________________________ Address: ___________________________________ City/State: __________________________________ Telephone: ( ) Attorney I.D.: _______________________________ DIV105 State ENG Rev 12/01-D www.courts.state.mn.us/forms Page 8 of 8