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This is a Minnesota form that can be used for Family within Local County, Hennepin, District Court.
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STATE OF MINNESOTA COUNTY OF HENNEPIN FOURTH JUDICIAL DISTRICT COURT FAMILY COURT DIVISION Court File No. ________________ _______________________________________ Petitioner, and _______________________________________ Respondent. PETITIONER'S RESPONDENT'S INITIAL CASE MANAGEMENT CONFERENCE DATA SHEET You must complete and send this form to the assigned Judicial Officer, but DO NOT FILE the form with the Court. You must mail, e-mail or fax the form to the Judicial Officer at least 3 DAYS before the Initial Case Management Conference (ICMC). The addresses are on the attached Notice of Case Assignment. The information is only used to give the Judicial Officer some basic information about your case. You must also mail a copy of the completed form to the other party before the ICMC or bring a copy for the other party to the ICMC. 1. BASIC INFORMATION: a. Your birth date: ______________________ c. b. Date of marriage (if married): ________________________ Your mailing address: ________________________________________________________________________ d. Your phone number(s): _______________________________________________________________________ e. Your e-mail address(es): ______________________________________________________________________ f. Do you have any physical, mental health and/or chemical dependency issues that may affect this case? If so, briefly explain: ______________________________________________________________________________ 2. CHILDREN: a. List the names, birthdates and ages of minor children involved in this case: Name Birth date Age Who does the child live with b. Do any of the above children have special needs? If yes, briefly explain: __________________________________________________________________________________________ __________________________________________________________________________________________ c. Do you have an agreement about parenting issues? If yes, what is the agreement? __________________________________________________________________________________________ __________________________________________________________________________________________ d. Current parenting time arrangements: ____________________________________________________________ __________________________________________________________________________________________ 3. OTHER RELATED COURT CASES: Are you or the other party involved in any of the following court cases: a. Child protection court cases b. Paternity cases c. Child support cases Court file # if known ___________________________ Court file # if known ___________________________ Court file # if known ___________________________ Court file # if known ___________________________ Court file # if known ___________________________ Court file # if known ___________________________ Court file # if known ___________________ American LegalNet, Inc. www.FormsWorkFlow.com d. Domestic abuse cases ("OFP") e. Harassment cases ("HRO") f. Criminal cases g. DANCO (criminal domestic abuse no contact order) FAM### Dist4 ENG Rev 6/1/16 www.MNCourts.gov/Hennepin p. 1 of 2 4. INCOME INFORMATION: a. Name of your employer: ______________________________________________________________________ b. How many hours a week do you work? _______ hourly wage: __________ or monthly salary ______________ c. Do you receive any of the following? Cash public assistance (MFIP) General assistance (GA) Supplemental security income (SSI) (check all that apply) Medical assistance Food stamps Diversionary work program (DWP) Child care assistance Other d. List any other sources of income: _______________________________________________________________ Attach copies of your 5 most recent paystubs; and verification of any other income. 5. ASSETS & DEBTS do you own or have an interest in: (only complete if this is a divorce case) a. A homestead b. Other real estate c. Retirement accounts Fair market value _______________ Mortgage balance __________ No Fair market value _______________ Mortgage balance __________ Balance 1) _____________ 2) ______________ 3) ______________ Balance 1) _____________ 2) ______________ 3) ______________ Name ___________________________________________________ Year/make/model/value: d. Checking/savings accounts e. A business f. Vehicles 1) __________________________ 2) __________________________ 3) ____________________________ g. Other assets worth more than $5000 Yes Asset/value: 1) __________________________________________ 3) _________________________________________ 2) __________________________________________ 4) _________________________________________ h. List any assets that are non-marital: _____________________________________________________________ i. Your debts & approximate balances: Creditor: _____________________________________ Creditor: _____________________________________ Creditor: _____________________________________ Creditor: _____________________________________ 6. ALTERNATIVE DISPUTE RESOLUTION (ADR): a. Do you feel safe meeting in the same room with the ADR provider and other party to try to resolve the issues in your case? b. Do you feel free to participate, not participate or withdraw from an ADR process without fear of harm or the threat of harm, including when the process is over? c. Are you and the other party willing and able to negotiate freely, deal fairly with each other; follow the rules set up for the process and make your own decisions without fear of harm or the threat of harm, including after the process is over? Balance: ____________ Balance: ____________ Balance: ____________ Balance: ____________ Whose name: _________ Whose name: _________ Whose name: _________ Whose name: _________ _____________________________________________________________ Signature (attorney or self-represented party) Attorney: ____________________________________ Date I.D. Number: _______________________________________________________________________________________ Address: __________________________________________________________________________________________ Phone number(s) ___________________________________________________________________________________ E-mail address: ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com FAM### Dist4 ENG Rev 6/1/16 www.MNCourts.gov/Hennepin p. 2 of 2