CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 1 of 5 State of Minnesota District Court County Judicial District: Court File Number: Case Type: In Re the Custody of: Petition To Establish Custody and Parenting Time [Minn. Stat. 247 518.156] Petitioner Recognition of Parentage signed [Minn. Stat. 247 257.75, subd. 3] and Respondent 1. I am the Petitioner. My name and address: First Middle Last Street Address Apt. # City State Zip Code 2. The other parent is the Respondent. Respondent222s full name and address: First Middle Last Street Address Apt. # City State Zip Code 3. The names and dates of birth of the minor children involved in this action are: Child222s Full Name Date of Birth First Middle Last Month / Day / Year First Middle Last Month / Day / Year American LegalNet, Inc. www.FormsWorkFlow.com CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 2 of 5 4. The children currently live with: Me Other parent Other person (print full name of other parent or person): . The address of the children is: in the City of , County of , State of , zip code . The children have lived at this address since (mo/day/yr). If children have lived less than six months at the above listed address, list dates and locations of where the children have been living for the last six months: 5. Petitioner and Respondent signed a Minnesota Recognition of Parentage (ROP) for the minor children listed above. The Recognition of Parentage has been filed with the Minnesota Department of Health and is a basis for bringing an action to grant custody, parenting time, and/or child support pursuant to Minn. Stat. 247 257.75, subd. 3 (2010). (check one) Petitioner has included a certified copy of the Recognition of Parentage with this Petition. Petitioner requested a certified copy from the Minnesota Department of Health and will file it with the court when Petitioner receives it. 6. A court-appointed guardian or custodian has been appointed for the children. No Yes 226 A guardian or custodian has been appointed for the children by court order in Court File No. in the State of and the name of the guardian / custodian is (Note: Minn. Stat. 247 518.156, subd. 2, requires the Petitioner to give written notice of this proceeding to the guardian / custodian.) American LegalNet, Inc. www.FormsWorkFlow.com CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 3 of 5 7. Petitioner222s request for custody and parenting time: a. Legal Custody: Legal custody means having a right to participate in the major decisions regarding the child222s life, including education, religious upbringing and medical treatment. It is in the child222s best interests that legal custody is granted as follows: (check one) Joint legal custody to both parents Sole legal custody to Petitioner Respondent b. Physical Custody: Physical custody identifies who will handle the routine daily care and control of the child, and who the child will live with. It is in the child222s best interests that physical custody is granted as follows: (check one) Joint physical custody to both parents Sole physical custody to Petitioner Respondent 8. A child protection case involving the children in this case is open: YES NO If YES, this case is in County in the State of , and the Court File Number is . The child protection worker222s name is . 9. An Order for Protection involving me and the other parent (print full name) and/or the children is open: YES NO. If YES, this case is in County in the State of , and the Court File Number is . A copy of the Order for Protection is included with this Petition. 10. Parenting Time: It is in the child222s best interests that parenting time be granted as follows: Grant parenting time to the Petitioner Respondent American LegalNet, Inc. www.FormsWorkFlow.com CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 4 of 5 Grant supervised parenting time to the Petitioner Respondent Deny parenting time to the Petitioner Respondent 11. Child Support: (check one box) There is no existing child support order and Petitioner is asking the court to establish child support in accordance with child support guidelines. There is no existing child support order and child support is not being requested in this Petition. There is an existing child support order for the children named in this action, located in the County of , State of , Court File Number . The Petitioner requests that the Court grant the following relief: 1. I am asking the court to grant legal custody as follows: (pick one) Joint legal custody to both parents Sole legal custody to the Petitioner Respondent 2. I am asking the court to grant physical custody as follows: (pick one) Joint physical custody to both parents Sole physical custody to the Petitioner Respondent 3. I am asking the court to: (pick one) Grant parenting time Grant supervised parenting time to the Petitioner Respondent Deny parenting time to the Petitioner Respondent American LegalNet, Inc. www.FormsWorkFlow.com CHC103 State ENG Rev 8/18-D www.mncourts.gov/forms Page 5 of 5 4. Optional 226 only check box if asking the court for child support. I am asking the court to establish child support according to the child support guidelines. Child support includes basic support, medical support, and child care support. 5. Granting such other and further relief as the court may deem just and equitable. DATE: Signature Street Address City/State/Zip Code ( ) Telephone Number E-mail address American LegalNet, Inc. www.FormsWorkFlow.com