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Parenting-Financial Statement Disclosure FAM-108 - Minnesota

Parenting-Financial Statement Disclosure Form. This is a Minnesota form and can be used in Dissolution District Court Statewide .
 Fillable pdf Last Modified 1/24/2014
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State of Minnesota County Judicial District: Court File Number: Case Type: District Court In Re the Marriage of: In Re the Custody of: Name of Petitioner and Petitioner's Respondent's Parenting / Financial Disclosure Statement (Minn. Gen. R. Prac. 305) Name of Respondent 1. Background Information a. b. c. d. e. Full Name Age Years of Marriage (if applicable) Petitioner ________________________ ________________________ Respondent _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Separation Date (if applicable) Present Mailing Address 2. Court Order(s) Prohibiting Contact a. Is there an existing court order between you and the other party? (check all that apply) FAM108 State Harassment Restraining Order (HRO) Domestic Abuse Order for Protection (OFP) No Contact Order Other court order prohibiting contact with the other party: _______________________ ENG 5/12 www.mncourts.gov/forms Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com b. Have you been or are you now afraid of the other party? Yes No If yes, please explain: ______________________________________________________ ________________________________________________________________________ 3. Information Regarding The Minor Joint Children List the names, birth dates, and ages of the minor joint child(ren) of this legal action: Full Name of Child Birth Date Age a. Do any of the minor joint children have special needs? Yes No If yes, please explain: ______________________________________________________ Is there an agreement regarding parenting time? Yes No If yes, what is the parenting time arrangements for the child(ren)? ___________________ Have you and the other party created a parenting plan? b. c. d. Yes No Is there an agreement regarding legal custody of the child(ren)? Legal custody means having a right to participate in the major decisions regarding the child's life, including education, religious upbringing and medical treatment. Yes No If yes, what is the legal custody agreement? ____________________________________ ________________________________________________________________________ e. Is there an agreement regarding physical custody of the child(ren)? Physical custody identifies who will handle the routine daily care and control of the child, and who the child will live with. Yes No If yes, what is the physical custody agreement? __________________________________ ________________________________________________________________________ f. If you have other nonjoint children, list first and last initials of each nonjoint child's name, age and date of birth: ________________________________________________________________________ FAM108 State ENG 5/12 www.mncourts.gov/forms Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com g. h. Is the wife now pregnant? NO YES, the due date is: _______________ .(if applicable) Please indicate the name of the agency used for complying with the education requirement and the date scheduled or attended: ________________________________ 4. Employment and Income: a. Are you employed? If yes, where? Length of employment: Monthly Income Received Amount Monthly Income Received Amount Yes No Salary and Wages (before deductions Self-Employment Unemployment Benefits Commissions - Average Spousal Maintenance Received Bonus income - Average Supplemental Security (SSI) Total monthly income received: $ $ $ $ $ $ $ Social Security Received (social security disability, retirement, survivors' benefit) Child's Derivative Social Security or Veteran's Benefits Workers' Compensation Pension or Annuity Payments Military and Naval Retirement Other source of income (list source below) $ $ $ $ $ $ $ b. Do you or the other party receive any child support for nonjoint childen? Yes No If Yes, state who receives it and how much per month: c. Are you or the joint children currently receiving any form of public assistance? Yes (check all that apply) No Cash public assistance (MFIP) Food Stamps General Assistance Medical Assistance MinnesotaCare Child Care Subsidy Diversionary Work Program (DWP) TEFRA Other : FAM108 State ENG 5/12 www.mncourts.gov/forms Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com d. If you checked any boxes above in 4c above, did you serve the County Attorney's Office with a copy of your documents, as required? Yes No e. If you are not working, what is your source of income or support? 5. Monthly Living Expenses Expense Type Cost Monthly Income Received Amount Rent / Mortgage Payment $ Contract for Deed / 2nd Mortgage Homeowner's / Rental Insurance Property Taxes (if not included in mortgage payment) Heating & Electric Food Telephone / Cell Phone Child Care Payments Total monthly expenses: $ $ $ Transportation (car payment, gasoline, bus, taxi Medical and Dental Expenses (not covered by insurance) Cable TV / Internet Car Insurance $ $ $ $ $ $ $ $ Clothing Other Spousal Maintenance payments Other Child support payments Other Miscellaneous payments $ $ $ $ 6. Monthly Withholdings: a. b. Federal Income Tax Deductions State Tax Deductions: $______________ $ Social Security (FICA) and Medicare $______________ Retirement Contribution Union Dues Health Care / Medical Dental Coverage c. Other Paycheck Deductions (specify) ______________________ ______________________ d. Subtotal Deductions $______________ $______________ $______________ $______________ $______________ $______________ $______________ FAM108 State ENG 5/12 www.mncourts.gov/forms Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com e. f. NET TAKE HOME PAY Tax withholding figures above are based on Married/Single taxpayer status with what number of deductions? (Example: M-4 or S-2) $______________ _______________ g. Do you have medical and dental insurance coverage in place? Yes No If so, who is covered? ________________________________________________________ Questions 7 through 11 apply only for marital dissolution actions. 7. 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 7A. Homestead a. b. c. d. e. f. g. Date Acquired Purchase Price Present Fair Market Value Balance due on Mortgage Present Net Value (c ­ d) Monthly Payment (PITI) Rental Income, if any ____________ $___________ $___________ $___________ $___________ $___________ $___________ Other Property __
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