State of Minnesota County Judicial District: Court File Number: Case Type: District Court ___________________________________, Name of Petitioner (first, middle, last) ___________________________________, Name of Co- Petitioner, if any (first, middle, last) and PETITION FOR THIRD PARTY CUSTODY Minn. Stat. Ch. 257C ___________________________________, Name of Respondent Parent A (first, middle, last) ___________________________________, Name of Respondent Parent B (first, middle, last) ___________________________________. Name of Respondent Guardian or Custodian (first, middle, last) Do not write outside of the lines provided. If you need more space, attach another full sheet of paper. Part 1: Information about Parties and Children 1. Information about the Petitioner (you) First Middle Last Street Address Apartment or Unit Number City State Zip Your other names (maiden, former married or other legal name, alias). If none, write "none": Your relationship to the minor children: Co-Petitioner If you are the only petitioner, leave this Co-Petitioner section blank, and check here: CHC603 State ENG 5/17 www.mncourts.gov/forms Page 1 of 24 American LegalNet, Inc. www.FormsWorkFlow.com First Middle Last Street Address Apartment or Unit Number City State Zip Co-Petitioner's other names (maiden, former married or other legal name, alias). If CoPetitioner has not used a different name before, write "none." Describe Co-Petitioner's relationship to you: (for example, married, sisters, parent and child) Describe Co-Petitioner's relationship to the children: 2. Information about the Respondents a. Respondent Parent A First Middle Last Street Address Apartment or Unit Number City State Zip Parent A's other names (maiden, former married or other legal name, alias). If Parent A has not used a different name before, write "none." Parent A's social security number is listed on Form 11.1 and on file with the court. Parent A's social security number is unknown. How is Respondent Parent A related to the children? biological mother biological father adoptive parent b. Respondent Parent B First Middle Last CHC603 State ENG 5/17 www.mncourts.gov/forms Page 2 of 24 American LegalNet, Inc. www.FormsWorkFlow.com Street Address Apartment or Unit Number City State Zip Parent B's other names (maiden, former married or other legal name, alias). If none, write "none."___________________________________________________________ Parent B's social security number is listed on Form 11.1 and on file with the court. Parent B's social security number is unknown. How is Respondent Parent B related to the children? biological mother biological father adoptive parent c. Respondent (Legal Guardian or Custodian): First Middle Last Street Address Apartment or Unit Number City State Zip Respondent Legal Guardian or Custodian's other names (maiden, former married or other legal name, alias). If none, write "none." Describe the relationship between the Respondent Legal Guardian or Custodian and the children: 3. Paternity ­ Check all that apply: i. Court Order There is a court order in the State of ________________________ that says Parent _____ (A or B) is the father of the following children: ii. Minnesota Recognition of Parentage (ROP) The parents signed a Minnesota Recognition of Parentage (ROP) for the following children: CHC603 State ENG 5/17 www.mncourts.gov/forms Page 3 of 24 American LegalNet, Inc. www.FormsWorkFlow.com and each ROP was filed with the Minnesota Department of Health (this is usually done at the hospital or at a county office). iii. Voluntary Acknowledgment of Paternity or Parentage (VAP) in another state The VAP is like the Minnesota ROP, but for a different state. The parents signed a VAP in a state other than Minnesota for the following children: and the VAP is filed in the following state: . iv. Other reasons Respondent Parent _____ (A or B) is presumed to be the father of the children Check all that apply: The Respondent Parents were married when the following children were born: The following children were born within 280 days after Respondent Parents were divorced (or after the marriage of the Respondent Parents ended by death, annulment, declaration of invalidity, or after a decree of legal separation was entered by a court): Father receives the following children into his home, and openly holds them out as his biological children: Paternity genetic testing was done, and it shows that Respondent Parent _____ is likely to be the father of the following children: Petitioner believes that Respondent Parent _____ is the father of the following children: because: Other: CHC603 State ENG 5/17 www.mncourts.gov/forms Page 4 of 24 American LegalNet, Inc. www.FormsWorkFlow.com 4. Active Duty Military Service None of the petitioners or respondents is an active duty member of the Armed Forces. OR ___________________________ is an active-duty member of the Armed Forces. (Name of Party) His or her Commanding Officer is: Name/Rank Street Address City/State/Zip 5. Jurisdiction ­ Are you asking for custody of the children as a De Facto Custodian or as an Interested Third Party? Choose a or b, but not both. If you are not sure which to choose, please look at the Instructions (CHC601) for guidance. a. De Facto Custodian Number of months (out of the last 24 months) you have been the children's primary caretaker Name of child Child's age Note: the months in the third column do not have to be all in a row. During the time the children lived with you, did either parent also live with you? Yes No Has either parent been active in the children's lives on a regular basis while the children lived Yes No with you? b. Interested Third Party Check all that apply: I do not qualify as a De Facto Custodian. The parents have abandoned, neglected, or otherwise shown a disregard for the children's wellbeing AND the children would be harmed by living with either parent CHC603 State ENG 5/17 www.mncourts.gov/forms Page 5 of 24 American LegalNet, Inc. www.FormsWorkFlow.com because The children are in physical or emotional danger if they live with either parent because There are other grave and weighty reasons (very important reasons) that make it necessary for the children to live with you. Explain these reasons: 6. Information about the Children a. Children's names and dates of birth: Name of Child Example: Jane Kay Smith Child's Age 3 years old Child's Date of Birth 11/1/2013 b. Are you aware of any other court cases involving the