Minnesota > Statewide > District Court > Dissolution
Application For Temporary Relief (With Children) DIV-1004 - Minnesota
| Application For Temporary Relief (With Children) Form. This is a Minnesota form and can be used in Dissolution District Court Statewide . |
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State of Minnesota County Judicial District: Court File Number: Case Type: District Court Dissolution In Re the Marriage of: Name of Petitioner/Plaintiff Petitioner's Respondent's Application for Temporary Relief and Name of Respondent/Defendant STATE OF MINNESOTA COUNTY OF (County where Affidavit signed) My name is (check one): Petitioner/Plaintiff ) ) SS ) and I state under oath that I am the Respondent/Defendant in this case, and in this I Application for Temporary Relief, I will be referred to as the: Husband Wife. understand that as I fill out this Application for Temporary Relief, I am under oath and must tell the truth. 1. The parties were married on (month/day/year) Wife's age is 2. years and the Husband's age is years. . The The parties have been separated Wife Husband has paid $ month(s), during which time: to the: Wife Husband. 3. a. During the marriage, the following child(ren) were born to or adopted by the parties: Child's Address Child's Full Name Date of Birth Lives With (Street Address, City, (first, middle, last) State, Zip Code) DIV1004 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 1 of 6 American LegalNet, Inc. www.FormsWorkflow.com b. The family home is: owned rented The family home is now occupied by: by the parties. Wife Husband Both parties. Other person(s) live in the home (please specify): c. It is in the best interests of the child(ren) that the child(ren) be in the physical custody of the wife husband reasons) both parties because (specifically explain your d. The wife has minor child(ren) from a previous marriage or relationship. per month for the support of the The wife: pays receives $ minor child(ren). e. The husband has minor child(ren) from a previous marriage or relationship. per month for the support of the The husband: pays receives $ minor child(ren). 4. The parties have the following assets: Description of Asset a. Car market value Balance due Year/Make b. Stocks, Bonds, Notes c. Cash and Savings d. Accounts Receivable e. Homestead/Real Estate $ $ $ $ Wife uses or in wife's name $ $ / Husband uses or in Husband's name $ $ / $ $ $ $ Both use or in both names $ $ / $ $ $ $ DIV1004 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 2 of 6 American LegalNet, Inc. www.FormsWorkflow.com 5. Secured debts (not including those listed above and not including homestead; attach additional sheets, if necessary): Name of Creditor Balance Due $ $ $ $ $ $ $ $ $ $ Monthly Payment Party Obligated Security Pledged 6. Necessary Monthly Expenses (for you and the child(ren) if the child(ren) live with you): Monthly Expense 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 m. Car Insurance n. Life Insurance o. Recreation/Travel p. Newspapers/Magazines q. Social, Church obligations r. Personal Allowances/Incidentals s. Babysitting and Day Care $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Wife/Husband Expenses Child(ren) Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ DIV1004 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 3 of 6 American LegalNet, Inc. www.FormsWorkflow.com t. Home Maintenance u. Child(ren)'s School Needs v. Child(ren)'s Allowances w. Additional info (explain): $ $ $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY EXPENSES $ $ 7. Provide the following data for each employer. Attach paycheck stub(s) for the last month, or if available, the last three month(s): Husband a. Name of Employer Type of Employment b. Income: (1) Gross Income per month (monthly income is to be calculated using a 4.3 multiple). Wife $ $ (2) Statutory Deductions Federal Income Tax State Income Tax Social Security, FICA, 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 Pay Deductions (specify) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ DIV1004 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 4 of 6 American LegalNet, Inc. www.FormsWorkflow.com $ (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 (for $ $ $ $ $ $ $ example; M-4, S-2): d. Employer reimbursed expenses Specify: $ $ e. Other income (1) Public Assistance (AFDC/GA) (2) Social Security Benefits for party or child(ren) (3) Unemployment/Worker's Comp. (4) Interest income per (5) Dividend income per (6) Gross rental income (7) Other: 8. a. $ support for b. $ support for $ $ $ $ $ $ $ $ $ $ $ $ $ $ per month is a reasonable amount to be paid by me for temporary (number of) child(ren). per month is a reasonable amount to be paid to me for temporary (number of) child(ren). c. Payment should be made on the first (1st) and fifteenth (15th) of each month starting on (month, day, year) 9. a. $ b. $ c. $ costs. has been paid on wife's attorney's fees and costs. has been paid on husband's attorney's fees and costs. is reasonable for the: Wife's Husband's attorney's fees and . DIV1004 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 5 of 6 American LegalNet, Inc. www.FormsWorkflow.com 10. Additional Material Facts: Based upon the above information, I ask the Court for an Order granting such relief prior to trial as may be just and lawful. Dated: Signature of: Petitioner Respondent (Sign only in front of notary public or court administrator.) Name: Sworn/affirmed before me this day of , . Address: City/State/Zip: Telephone: ( Notary Public \ Deputy Court Administrator ) DIV1004 State ENG Rev 1/02-D www.courts.state.mn.us/forms Page 6 of 6 American LegalNet, Inc. www.FormsWorkflow.com
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