Fill and Sign the Prehearing Statement Form

- 1 - STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, DEFENDANT’S PREHEARING STATEMENT AND , Respondent, 1. PE R SO NAL I N FO RM ATIO N PL A IN TIF FD EFE N DANT Full n am ePre se n t m ailin g a d dre ssE m plo yer S tr e et a d dre ss C ity , S ta te , Z IPB ir th d atea g e:ag e:M arria g e d ate : S ep ara tio n d ate ( D if fe re n t r e sid en ces): D ate (s ) o f T em pora ry O rd er( s ), i f a n y: M in or c h ild re n b orn t o t h is m arria g e o r w ho w ill b e a ffe cte d b y t h is l e g al a ctio n: F U LL N AM E BIR TH DATE A GE LIV IN G W IT H : - 2 - Is t h e D efe n dan t n ow p re g n an t? n o y es - d ue d ate o f _ ____________. Is t h e i s su e o f c u sto dy c o nte ste d ? y es n o If c u sto dy i s d is p ute d , e ach p arty s h all s u bm it p ro posa ls f o r c u sto dy a n d v is ita tio n f o r e ach c h ild o n E xhib it 1 A . See E xh ib it 1 A a tta ch ed h ereto . 2. EM PL O YM EN T: P ro vid e t h e f o llo w in g d ata f o r e ach e m plo yer. P la in tif f D efe n dan t ( a ) N am e o f e m plo yer L en gth o f e m plo ym en t P la in tif fD efe n dan t I n co m e: ( 1 ) G ro ss i n co m e e v ery _ ___________ S ta tu to ry d ed uctio ns: F ed era l i n co m e t a x S ta te w ith hold in g S ocia l s e cu rity ( F IC A ) P en sio n d ed uctio ns U nio n d ues D ep en den t h ealth /H osp it a liz atio n c o vera g e D en ta l c o v era g e ( 2 ) S ubto ta l o f s ta tu to ry d ed uctio ns: ( 3 ) N et i n co m e ( lin e 1 - l in e 2 ): O th er p ay ch eck d ed uctio ns: S pecif y : ( 4 ) S ubto ta l ( O th er d ed uctio ns): ( 5 ) N ET T A K E H OM E P A Y P E R ( lin e 3 - l in e 4 ) __ _____ ________ P A Y P E R IO D: - 3 - Tax w it h hold in g f ig ure s a b ov e a re b ase d o n M arrie d o r S in gle tax pay er w ith # o f e x em ptio n s: ( E xam ple : M -4 o r S -2 ):A tta ch ed p rio r m onth 's p ay ch eck s tu b(s ) a s E xhib it 2 A . ( b ) E m plo ym en t b en efits : I d en tif y a ll b en efits i n a d dit io n t o w ag es in clu din g b on us p aid o r d ue, a u to m obile o r t r a v el e x pen se re im burs e m en t, o th er p er d ie m c o m pen sa tio n, m em bers h ip s p aid b y the e m plo yer.W ill y our m ed ic al a n d d en ta l i n su ra n ce c o vera g e b e a v aila b le f o r y our s p ouse a fte r t h e d is so lu tio n? _ __Y es __ _N o N /A ( c ) O th er i n co m e: ( 1 ) P ublic a ssis ta n ce ( A FD C/G A) ( 2 ) S ocia l S ecu rity b en efits f o r p arty o r c h ild (re n ) ( 3 ) U nem plo ym en t/W ork ers C om p. ( 4 ) I n te re st i n co m e p er _ _________________ ( 5 ) D iv id en d i n co m e p er _ _________________ ( 6 ) O th er i n co m e ( 7 ) L ast y ea r's t a x r e fu nd sF ed era l:S ta te :F ed era l:S ta te :3 . C H IL D S U PPO RT/S PO USA L M AIN TEN ANCE(a ) D oes e ith er p arty r e ceiv e c h ild s u pport o r s p ousa l m ain te n an ce f ro m a s e p ara te p ro ceed in g? y es n o. If ye s, s p ecif y th e $ ________ _____ r e ceiv ed e ach m onth f o r c h ild s u pport/a lim ony f o r _ ____________ b y th e o rd er of _ ____________ C ounty , d ate d _ ____________. ( b ) C hild S upp ort o r S pousa l M ain te n an ce esta b lis h ed b y co urt fo r p ers o n(s ) n ot in clu ded in th is p ro ceed in g curre n tly b ein g p aid : $ _ ____________ $ _ ____________ T o w hom i s t h is o blig atio n o w ed ? ______________ ____________ C ounty a n d D ate o f s u ch O rd er: ______________ ____________(c ) C urre n t M onth ly C hild S upport o r S pousa l M ain te n an ce O rd er e sta b lis h ed b y te m pora ry o rd er f o r o th er p arty an d m in or c h ild re n i n t h is p ro ceed in g: C hild s u pport: $ _ ______ ______ S pousa l m ain te n an ce ( A lim ony): $ _ ____________ - 4 - A re t h ere a n y c la im ed a rre ara g es u nder e x is tin g c o urt o rd er(s ): y es n o I f y es, s p ecif y t h e a m oun t( s ) c la im ed : C hild s u pport $ _ ____________ S pousa l m ain te n an ce ( A lim ony) $ _ ____________4. LIV IN G E X PE N SE S: Y our e stim ate d m onth ly e x pen se s: $ _ ____________ [ E nte r t o ta l f ro m i te m iz ed s c h ed ule t o b e a tta ch ed a s E xhib it 4 A ] See E xh ib it 4 A a tta ch ed h ereto . 5. REA L P R O PE R TY :HOM EST EA D O TH ER * a) D ate A cq uir e db ) P urc h ase P ric ec ) P re se n t F air M ark et V alu ed ) F ir s t M ortg ag e B ala n cee ) S eco nd M ortg ag e B ala n ce o r H om e I m pro vem en t L oanf) N et V alu eg ) M onth ly P ay m en t: ( P IT I)h ) R en ta l I n co m e, i f a n y * O th er r e al e sta te : P ro vid e th e s a m e in fo rm atio n f o r o th er r e al p ro perty s u ch a s r e n ta l p ro perty , la k e c ab in , e tc ., a s Ex hib it 5 C .6. PE R SO NAL P R O PE R TY : F air m ark et v alu eIn p osse ssio n o f: P L A IN TIF FD EFE N DANT JO IN T a) H ouse h old c o nte n tsb ) S to ck s, b o nds, e tc .c ) C heck in g a cco unts S av in gs a cco untsd ) R eceiv ab le s a n d c la im se) M oto r v eh ic le s: - 5 - Y ear/m ak e/m odel: M ark et v alu e: E ncu m bra n ce: N et v alu e: M onth ly p ay m en t: I n p osse ssio n o f:f) B oats , m oto rs , c am pers , s n ow - m obile s, t r a ile rs , e tc .: Y ear/m ak e/m odel: M ark et v alu e: E ncu m bra n ce: N et v alu e: M onth ly p ay m en t: I n p osse ssio n o f:g ) O th er: ( s u ch a s p ow er e q uip m en t, t o ols , g uns, v alu ab le a n im als , e tc . D esc rip tio n : F air m ark et v alu e: E ncu m bra n ce: N et v alu e:7 . NONM ARIT A L C LA IM S: N /Aa ) Desc rip tio n: ( 1 ) _ __ __________ ( 2 ) _ _______ _____b) Am ount c la im ed : $ _ ____________ $ _ ____________S et f o rth t h e b asis f o r a n d m eth od u se d t o a rriv e a t y our c la im s t o b e a tta ch ed a s E xhib it 7 A .8. LIF E I N SU RA NCE:a) b ) c ) C om pan y:P olic y n um ber:T ype o f i n su ra n ce:F ace a m ount: - 6 - C ash v alu e:L oan s:In su re d :B en efic ia ry :O wner:9 . PE N SIO N P L A N A ND/O R P R O FIT -S H ARIN G P L A N: PL A IN TIF FD EFE N DANT a) T hro ugh e m plo ym en t: ( 1 ) P re se n t c ash v alu e ( 2 ) V este d o r n on v este db ) P riv ate p la n s: ( I R A , K eo gh, S E P, e tc .) ( 1 ) P re se n t c ash v alu ec) D efe rre d c o m pen sa tio n:d ) M ilita ry p en sio n o r d is a b ility :Y es N o Y es N o 1 0 . DEB TS: ( N ot l is te d i n p ara g ra p hs 4 o r 5 a b ove)a) A ll s e cu re d d eb ts : C re d ito r T ota l a m ount o w in g M onth ly p ay m en t W hen i n cu rr e d P arty o blig ed ( P ,D ,J ) R easo n f o r d eb tT ota ls :P la in tif f:$ _ __ __________D efe n dan t:$ _ __ __________Jo in t:$ _ __ _____ b ) U nse cu re d d eb ts : A tta c h a s e p ara te s c h ed ule s h ow in g th e c re d ito r, b ala n ce o w ed , m onth ly p ay m en t, e tc ., to b e atta ch ed a s E xhib it 1 0B . I n clu de a tto rn ey f e es a n d c o sts . - 7 - T ota ls :P la in tif f: Defe n dan t: Jo in t: $ _________ ____ $ _ ____________ $ _ ____________ S ee E xh ib it 9 B a tta ch ed h ereto . D ate d : _ _____ _______ T he s ta te m en ts c o nta in ed h ere in a re t r u e a n d c o m ple te t o t h e b est o f m y k now le d ge. _ _____________________________D efe n dan t B y _ _________ __________ ________A tto rn ey s f o r D efe n dan t(A ddre ss)(A ddre ss)(C ity , S ta te ,Z ip )(T ele p hone N um ber)( A tto rn ey R eg . N o.: )