State of Minnesota County Judicial District: Court File Number: Case Type: District Court In Re the Custody of: Born (mo/day/yr) Affidavit in Support of Responsive Motion to Establish Custody and Parenting Time Petitioner and Respondent STATE OF MINNESOTA ) ) SS COUNTY OF _______________________ ) My name is 1. and I state that: I am the Respondent in this case, and I make this Affidavit in support of my responsive motion for custody and parenting time (visitation). 2. A child protection case involving any or all of the children in this case is open: YES NO. If YES, this case is in , and the case file number is The child protection worker's name is 3. An Order for Protection involving me and the Petitioner and/or the child(ren) exists: YES NO. County in the State of . . CHC203 State ENG Rev 07/15 www.mncourts.gov/forms Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com If YES, this case is in , and the case file number is A copy of the Order for Protection is attached. 4. The children currently live with: County in the State of . Me Petitioner Other person (print full name): . . . I am the child(ren)'s: (list relationship) The other party is the child(ren)'s:(list relationship) The address of the child(ren) is/are: in the City of Zip Code (mo/day/yr) 5. , State of , . The child(ren) have lived at this address since: . I want the Court to grant legal custody of the child(ren) (check one): a. Jointly to both me and Petitioner because b. Solely to (check one): Me Petitioner because 6. I want the Court to grant physical custody of the child(ren) (check one): a. Jointly to both me and Petitioner with the child(ren) living with me at the following times: CHC203 State ENG Rev 07/15 www.mncourts.gov/forms Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com and the child(ren) living with Petitioner at the following times: b. Solely to (check one): Me Petitioner 7. I believe that my request for physical custody is in the best interest(s) of the child(ren) because (list your reasons why, be specific) 8. I want to respond to things the other party stated at paragraph 4 of his/her Affidavit. My response is: 9. I want the parenting time schedule as stated in my Responsive Motion. I believe that this schedule is in the best interest(s) of the child(ren) because CHC203 State ENG Rev 07/15 www.mncourts.gov/forms Page 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 10. I want to respond to the other party's requests for parenting time. My response is: 11. I want the Court to order to order supervised parenting time: YES NO If yes, I believe supervised parenting time is in the best interest(s) of the child(ren) because: 12. The Petitioner has asked the Court to order supervised parenting time for me and the child(ren): YES NO If yes, I object. My response to Petitioner's statements in paragraph 5 of his/her Affidavit is: 13. I want the Court to order that the child(ren) be transferred at a visitation exchange center if one is located in the area, and for both parties to follow all rules of the visitation exchange center: YES NO. If YES, this is the best interest(s) of the child(ren) because If NO, the child(ren) should be transferred at: because CHC203 State ENG Rev 07/15 www.mncourts.gov/forms Page 4 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Note: The visitation exchange center may require the parties to pay a fee for each exchange. 14. Check all that apply: a. There is currently a court order requiring to pay child support to month. in the amount of $ per b. I am asking the Court to decide or modify child support based on Minnesota child support guidelines. c. Other: Current Information About Me 15. I am currently (check all that apply): Married Separated Divorced Living with a companion unemployed Single 16. I am currently (check one) employed following): a. Employer: b. Address: c. Work telephone number: d. Occupation /Type of work: e. Length of employment: f. Supervisor: (if employed, answer the g. Gross Pay: $_________________ This does does not include overtime pay. h. Paid: Weekly Every other week Twice a month Monthly i. Previously employed by ___________ years prior to the above employment. 17. I have the following additional sources of income: Commissions Annuity Payments $ $ Pension Payments $ Unemployment Benefits $ for CHC203 State ENG Rev 07/15 www.mncourts.gov/forms Page 5 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Military / Naval Retirement $ Spousal Maintenance Received $ Self-Employment 18. $ Workers' Compensation $ Disability Payments $ Other $ MinnesotaCare I receive (check only if it applies) MFIP Medical Assistance General Assistance SSI Child Care Assistance 19. The joint child(ren) currently receives monthly social security or veteran's benefits in the amount of $ based on my disability the other parent's disability and is paid to me other parent. I am court ordered to pay monthly spousal maintenance. (check one) YES NO If yes, how much? 20. 21. I support the following nonjoint child(ren): Child's Name Date of Birth Relationship Child support Living in monthly amount my home $ $ $ $ $ Yes / No Yes / No Yes / No Yes / No Yes / No (If ordered to pay child support for any child listed above, provide copies of court orders) 22. My monthly expenses at the present time are as follows (if remarried, include total of household expenses): Monthly Payment at Present Time a. House payment or Rent $ b. Real Estate Taxes, if not included in (a) $ c. Association Dues or Lot Rent (for property) $ d. Insurance: Homeowners, if not included in (a) $ Car $ Life $ e. Utilities: (Average Monthly Amount) Gas $ Electricity $ CHC203 State ENG Rev 07/15 www.mncourts.gov/forms Page 6 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Telephone / Cell Phone Water and garbage Cable TV f. g. h. i. j. k. l. m. n. Food Clothing Laundry/dry cleaning Personal allowances and incidentals Magazine and newspapers Uninsured / unreimbursed medical expenses Uninsured / unreimbursed dental expenses Child care expenses Transportation expenses: Car payment License Gasoline Repairs Recreation/Entertainment Child(ren)'s needs (sports/school/hobbies) Allowances Other (list) Charge accounts and loans (list): Name of Account 1. 2. 3. 4. 5. TOTAL MONTHLY EXPENSES: 23. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Balance Owed $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ o. p. q. r. s. The following people help