State of Minnesota County Judicial District: Court File Number: Case Type: District Court Family In Re the Custody of: Responsive Notice of Motion and Born (mo/day/yr) Motion to Establish Custody And Parenting Time Petitioner and Respondent TO: First Middle Last Street Address Apt. # City State Zip Code TO: First Middle Last Street Address Apt. # City State Zip Code NOTICE o'clock PLEASE TAKE NOTICE that on m., before of the , , at (Name of Judge or Judicial Officer) in room located at Minnesota, I will ask the Court for an Order granting me the following relief: CHC202 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com RESPONSIVE MOTION 1. The name(s) and date(s) of birth of the minor child(ren) involved are: Child's Full Name Date of Birth 2. My relationship to the child(ren) is: Mother Other 3. Legal custody identifies who will have a right to make decisions regarding the education, religious, and medical upbringing of the child(ren). Legal custody of the child(ren) should be granted: (check one) a. Jointly to both me and (Full Name) b. Solely to (check one): Me The other party (print full name) 4. Physical custody identifies with whom the child(ren) will live. Physical custody of the child(ren) should be granted to (check one): a. Jointly to both me and the Other Party: (Full Name) b. Solely to (check one): Me The other party (print full name) 5. Parenting Time for the minor child(ren) and (check one): Me Other party (print full name): Supervised Unsupervised should be (check one) 6. Parenting time with: Me Other party (print full name): should be scheduled as follows: (If joint physical custody is requested check both "Me" and CHC202 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com "Other party" and clearly explain when the child is with each parent. If sole physical custody is requested, clearly explain when the non-custodial parent will have parenting time (visitation) with the child.) parenting time schedule. a) Weekends: You may attach a separate sheet of paper setting out the b) Week nights or after school: c) Holidays: d) School release days: e) Birthdays: f) Summers: g) Telephone Contact: h) Other: 7. Child support should be paid as follows (check all that apply): CHC202 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com  a. The other party (Full name) should pay for The support of the minor child(ren) according to Minnesota child support guidelines. payments should be automatically withheld from the other party's wages and paid to me according to M.S. §518A.53. b. I should pay the other party (Full name of other party) for support of the minor child(ren) according to Minnesota child support guidelines. The payments should be automatically withheld from my wages and paid to the other party according to M.S. §518A.53. c. There is currently a court order requiring to pay child support to in the amount of $ court file no. d. Other: per month. The child support order is in . 8. Determining each party's obligation to pay medical support to the other party in regard to the child(ren) in his/her physical custody. 9. Determining each party's share of the cost of medical and dental expenses not covered by insurance and incurred by the child(ren). 10. Determining each party's share of the cost of the work or educational-related child care expenses in regard to the child(ren). 11. Granting additional relief as follows: CHC202 State ENG Rev 7/15 www.mncourts.gov/forms Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 12. Granting such other and further relief as the Court may deem just and equitable. VERIFICATION AND ACKNOWLEDGEMENTS a) I have read this document. To the best of my knowledge, information and belief, the information contained in this document is well grounded in fact and is warranted by existing law. b) I have not been determined by any Court in Minnesota or in any other state to be a frivolous litigant and I am not the subject of an Order precluding me from serving or filing this document. c) I am not serving or filing this document for any improper purpose, such as to harass the other party to cause delay or needless increase in the cost of litigation or to commit a fraud on the Court. d) I understand that if I am not telling the truth or if I am misleading the Court or if I am serving or filing this document for an improper purpose, the Court can order me to pay money to the other party, including the reasonable expenses incurred by the other party because of the serving or filing of this document, court costs and reasonable attorney's fees. Dated: Signature Name: Street Address: City/State/Zip: E-mail address: CHC202 State ENG Rev 7/15 www.mncourts.gov/forms Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com