STATE OF MINNESOTA DISTRICT COURT SECOND JUDICIAL DISTRICT COUNTY OF RAMSEY FAMILY COURT DIVISION ________________________________________________________________________ Petitioner, Application Form Cooperation for the Children and Court File No.: Respondent. INSTRUCTIONS: Complete this questionnaire to the best of your ability. Please use black ink pen for clear copies. PERSONAL INFORMATION: You Other Parent Name: Mailing Address: Home Telephone: When Available To Receive Calls: Employer: Address: Work Telephone: When Available To Receive Calls: Gross Income: $ Birth Date: Age Age 1 2001 © American LegalNet, Inc. Children who will be affected by this legal action: (If you need more room continue on back page.) Full Name Birth Date Age Living With REVIEW QUESTIONS AND CHECK OFF THE TYPE OF HELP YOU ARE ASKING FOR FROM THE COOPERATION FOR THE CHILDREN PROGRAM: 1. Please explain what brought you to court: 2. With respect to the child(ren) Please check those that apply: I currently have I am seeking Sole Legal Custody Joint Legal Custody Sole Physical Custody Joint Physical Custody Visitation 3. If you want to establish or change visitation, please explain the visitation schedule below: Weekends: Holidays: Summer: 2 2001 © American LegalNet, Inc. School: Telephone Contacts: Other: 4. Has the other parent of your child(ren) ever accused you of physical or emotional abuse? Yes No 5. Has the other parent of your child(ren) physically assaulted you by doing any of the following within the past five years? Slapping, pushing, hitting, kicking, choking, forcing sex, throwing something at you, using a knife or gun to assault or threaten you? (Circle those that apply.) Yes No 6. Have you ever physically assaulted the other parent of your child(ren) by doing the following within the past five years? Slapping, pushing, hitting, kicking, choking, forcing sex, throwing something at him/her, using a knife or gun to assault or threaten him/her? (Circle those that apply.) Yes No 7. Have you, the other parent, or your children ever left home because of violence or Yes No threat of violence? 8. Have you or the other parent of your child(ren) ever filed an Order for Yes No. Protection? If yes, list county(s) 9. I have concerns about the other parent’s use of drugs/alcohol? Yes No 10. Have you or the other parent of your child(ren) ever been diagnosed with a mental Yes No illness? 11. I can, without fear or hesitation, negotiate with the other parent of our child(ren) in the presence of a neutral third person? Yes No 12. Date you completed this form: 3 2001 © American LegalNet, Inc.