Fill and Sign the Prehearing Statement 497312521 Form

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. PERSONAL INFORMATION PLAINTIFF DEFENDANT Full name Present mailing address Employer Street address City, State, ZIP Birth date age: age: Marriage date: Separation date (Different residences): Date(s) of Temporary Order(s), if any: Minor children born to this marriage or who will be affected by this legal action: FULL NAME BIRTHDATE AGE LIVING WITH: Is the Defendant now pregnant? no yes - due date of _____________ . - 1 - Is the issue of custody contested? yes no If custody is disputed, each party shall submit proposals for custody and visitation for each child on Exhibit 1A. See Exhibit 1A attached hereto. 2. EMPLOYMENT: Provide the following data for each employer. Plaintiff Defendant (a) Name of employer Length of employment Plaintiff Defendant Income: (1) Gross income every ____________ Statutory deductions: Federal income tax State withholding Social security (FICA) Pension deductions Union dues Dependent health/Hospitalization coverage Dental coverage (2) Subtotal of statutory deductions: (3) Net income (line 1 - line 2): Other paycheck deductions: Specify: (4) Subtotal (Other deductions): (5) NET TAKE HOME PAY PER (line 3 - line 4) _______________ PAY PERIOD: Tax withholding figures above are based on Married or Single taxpayer with # of exemptions: (Example: M-4 or S-2): Attached prior month's paycheck stub(s) as Exhibit 2A. - 2 - (b) Employment benefits: Identify all benefits in addition to wages including bonus paid or due, automobile or travel expense reimbursement, other per diem compensation, memberships paid by the employer. Will your medical and dental insurance coverage be available for your spouse after the dissolution? ___Yes ___No N/A (c) Other income: (1) Public assistance (AFDC/GA) (2) Social Security benefits for party or child(ren) (3) Unemployment/Workers Comp. (4) Interest income per __________________ (5) Dividend income per __________________ (6) Other income (7) Last year's tax refunds Federal: State: Federal: State: 3. CHILD SUPPORT/SPOUSAL MAINTENANCE (a) Does either party receive child support or spousal maintenance from a separate proceeding? yes no. If yes, specify the $ _____________ received each month for child support/alimony for _____________ by the order of _____________ County, dated _____________ . (b) Child Support or Spousal Maintenance established by court for person(s) not included in this proceeding currently being paid: $ _____________ $ _____________ To whom is this obligation owed? _____________ _____________ County and Date of such Order: _____________ _____________ (c) Current Monthly Child Support or Spousal Maintenance Order established by temporary order for other party and minor children in this proceeding: Child support: $ _____________ Spousal maintenance (Alimony): $ _____________ Are there any claimed arrearages under existing court order(s): yes no If yes, specify the amount(s) claimed: Child support $ _____________ - 3 - Spousal maintenance (Alimony) $ _____________ 4. LIVING EXPENSES: Your estimated monthly expenses: $ _____________ [Enter total from itemized schedule to be attached as Exhibit 4A] See Exhibit 4A attached hereto. 5. REAL PROPERTY: HOMESTEAD OTHER* 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 *Other real estate: Provide the same information for other real property such as rental property, lake cabin, etc., as Exhibit 5C. 6. PERSONAL PROPERTY: Fair market value In possession of: PLAINTIFF DEFENDANT JOINT a) Household contents b) Stocks, bonds, etc. c) Checking accounts Savings accounts d) Receivables and claims e) Motor vehicles: Year/make/model: Market value: Encumbrance: Net value: Monthly payment: In possession - 4 - of: f) Boats, motors, campers, snow- mobiles, trailers, etc.: Year/make/model: Market value: Encumbrance: Net value: Monthly payment: In possession of: g) Other: (such as power equipment, tools, guns, valuable animals, etc. Description: Fair market value: Encumbrance: Net value: 7. NONMARITAL CLAIMS: N/A a) Description: (1) _____________ (2) _____________ b) Amount claimed: $ _____________ $ _____________ Set forth the basis for and method used to arrive at your claims to be attached as Exhibit 7A. 8. LIFE INSURANCE: a) b) c) Company: Policy number: Type of insurance: Face amount: Cash value: Loans: Insured: Beneficiary: - 5 - Owner: 9. PENSION PLAN AND/OR PROFIT-SHARING PLAN: PLAINTIFF DEFENDANT a) Through employment: (1) Present cash value (2) Vested or non vested b) Private plans: (IRA, Keogh, SEP, etc.) (1) Present cash value c) Deferred compensation: d) Military pension or disability: Yes No Yes No 10. DEBTS: (Not listed in paragraphs 4 or 5 above) a) All secured debts: Creditor Total amount owing Monthly payment When incurred Party obliged (P,D,J) Reason for debt Totals: Plaintiff: $ _____________ Defendant: $ _____________ Joint: $ ________ b) Unsecured debts: Attach a separate schedule showing the creditor, balance owed, monthly payment, etc., to be attached as Exhibit 10B. Include attorney fees and costs. Totals: Plaintiff: Defendant: Joint: $ _____________ $ _____________ $ _____________ See Exhibit 9B attached hereto. - 6 - Dated: _____________ The statements contained herein are true and complete to the best of my knowledge. ______________________________ Defendant By ____________________________ Attorneys for Defendant (Address) (Address) (City, State,Zip) (Telephone Number) (Attorney Reg. No.:) - 7 -