CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 1 of 11 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Affidavit in Support of Establishing Custody and Parenting Time Petitioner and Respondent My name is and I state that: 1. I am the Petitioner in this case, and I make this Affidavit in support of my request that the court decide custody and parenting time. Optional: (check only if requesting) I am asking the court to establish child support 2. I want the court to grant legal custody of the children (check one): a. Jointly to both parents b. Solely to (check one): Me Other party (print full name): 3. I want the court to grant physical custody of the children (check one): a. Jointly to both parents b. Solely to (check one): Me Other parent (print full name): 4. Best Interest Factors. I understand that the Judge must decide custody based on what is best for my children, and that by filling in (a) through (l) of this paragraph 4, that I am giving the judge information needed to make that decision. a. Describe the children222s physical, emotional, cultural, spiritual, and other needs. : American LegalNet, Inc. www.FormsWorkFlow.com CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 2 of 11 Describe how the custody and parenting time arrangements you are asking the court to order will affect the children222s needs and development: b. Describe any special medical, mental health, or educational needs of the children that may require special parenting arrangements or access to recommended services: c. Describe the custody arrangement the children want (the court will decide if the children are of sufficient ability, age, and maturity to state an independent and reliable opinion): d. There is/was is not/was not domestic abuse in my household or relationship with the other parent. There is/was is not/was not domestic abuse in the other parent222s household. If there is or was domestic abuse, describe what happened, when the abuse happened, and the situation surrounding the abuse. If there is/was abuse, describe how that abuse may affect parenting, and the children222s safety, well-being, and developmental needs: e. Describe any physical, mental, or chemical health issues you or the other parent may have that affects the children222s safety or developmental needs (Chemical health issues could mean issues with drugs, alcohol, or other illegal substances): f. Describe what you have done in the past as well as each and every day to take care of the children: American LegalNet, Inc. www.FormsWorkFlow.com CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 3 of 11 Describe what the other parent has done in the past as well as each and every day to take care of the children: g. Describe your willingness and ability to maintain consistent, ongoing care to the children and to meet the ongoing developmental, emotional, spiritual, and cultural needs of the children: Describe the other parent222s willingness and ability to maintain consistent, ongoing care to the children and to meet the ongoing developmental, emotional, spiritual, and cultural needs of the children: h. Describe how any changes to home, school, and community have affected or may affect the children222s well-being and development: i. Describe how the custody and parenting time you want the court to order will affect the ongoing relationships between the children and each parent, siblings, and other significant persons in the children222s life: j. Describe how it will help the children to have as much parenting time with each parent as possible and how it may harm the children if parenting time with either parent is limited: k. Describe what you do to encourage the child222s relationship with the other parent and permit frequent and continuing contact by the other parent with the children (except when there is American LegalNet, Inc. www.FormsWorkFlow.com CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 4 of 11 domestic abuse): Describe what the other parent does to encourage or discourage your relationship and contact with the children: l. Describe the willingness and ability of you and the other parent to cooperate in the raising the children. How will you and the other parent share as much information as possible? How will you and the other parent work together to make sure the children are exposed to as little conflict as possible? Describe what methods you and the other parent plan to use for resolving disputes regarding any major decisions concerning the life of the children: 5. Parenting Time. I want the court to order parenting time as follows: Grant parenting time scheduled as stated below Grant supervised parenting time for the other parent Deny parenting time to the other parent (Use the space below to explain clearly when each parent will have the children. State the time (o222clock) when the children will transfer from one parent to the other. If you want the order to say who will pick up and drop off the children, or where the transfer of the children should take place, include that under 223Other.224) Regular Parenting Time Schedule Monday through Friday: Weekends: American LegalNet, Inc. www.FormsWorkFlow.com CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 5 of 11 Summer (if you want a schedule that is different than the regular one): Telephone contact with the children: Unlimited or Only at certain times as follows: (describe the days and times when the parent and children may have telephone contact) Exceptions to the Regular Schedule (You can have a different schedule for holidays, school release days, and birthdays. If you do not want a different schedule, leave it blank.) Do you want a different schedule for school release days or breaks during the school year? Yes No School release days or breaks during the school year: Any school release day schedule will override the regular parenting schedule. Do you want a different schedule for birthdays (child222s or parents222 birthdays)? Yes No Birthdays: Do you want a different schedule for holidays? Yes No State the specific holidays and the schedule for each holiday you list here: Any birthday or holiday schedule will override the regular and school release parenting schedule. American LegalNet, Inc. www.FormsWorkFlow.com CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 6 of 11 Other: 6. Overnights. Based on the schedule above, how many overnights will the children have with each parent each year (the number must add up to 365)? Note: if parenting time is equal, use 182.5 overnights for each parent. Number of overnights with Petitioner: Number of overnights with Respondent: 7. I believe that this schedule ordering supervised parenting time denying parenting time is in the best interest(s) of the children because If parenting time is supervised, parenting time should be supervised by: Note: You and/or the other parent may have to pay a fee for each supervised visit. 8. I want the court to order that the children be transferred at a visitation exchange center if one is located in the area, and for both parents to follow all rules of the visitation exchange center: YES NO. If YES, this is necessary because If NO, the children should be transferred at: because American LegalNet, Inc. www.FormsWorkFlow.com CHC105 State ENG Rev 8/18-D www.mncourts.gov/forms Page 7 of 11 9. Information about child support. Did you ask in question # 1 (on page 1) to establish child support? Yes No Continue only if asking to establish child support (child support includes basic support, medical support, and child care support). If not, go to the last page for signature. Current Information About Me I am currently (check all that apply): Married Separated Divorced Living with a companion Single 10. I am currently (check one) employed unemployed (if employed, answer the following): a. Employer: b. Address: c. Work telephone number: d. Occupation /Type of work: e. Length of employment: f. Supervisor: g. Gross Pay: $ This does does not include overtime pay. h. Paid: Weekly Every other week Twice a month Monthly i. Previously employed by for years prior to the above employment.