DIV1103 State ENG Rev 10/17www.mncourts.gov/formsPage 1 of 4State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Dissolution with Children Petitioner (First, Middle, Last) Respondent (First, Middle, Last) andIn Re the Marriage of:Affidavit in Support of Responsive Motion For Temporary Relief With Children My name is and I state that:1. I am the (check one): Petitioner Respondentin this case, and I make this Affidavit inin support of my Responsive Motion For Temporary Relief With Children.2. A child protection case involving any or all of the children in this case: (check one) is NOT taking place in any county or state IS taking place in County in the State of and the file number is:3. An Order for Protection involving me and the other party and/or the children: does NOT exist in any county or state DOES exist in County in the State of The Order for Protection is dated and the file number is:A copy of the Order for Protection is attached.4. My spouse and I have minor children who is/are: First Name of Child (first, middle, last) Date of Birth (mo/day/year) Age American LegalNet, Inc. www.FormsWorkFlow.com DIV1103 State ENG Rev 10/17www.mncourts.gov/formsPage 2 of 45. The children currently live with: who is the children's Petitioner Other Respondent Mother Other relation to children. The address of the children is: Father in the City of State of , Zip Code The children has/have lived at this address since the date6. I want the Court to grant temporary legal custody of the children: (check one) a. Jointly to me and my spouse because: b. Solely to (check one): me my spouse because 7. Write your response to paragraph 6 in the other party's Affidavit: 8. I want the Court to grant temporary physical custody of the children: (check one) a. Jointly to me and my spouse, with the children living with me at the following times: and the children living with my spouse at the following times: b. Solely to (check one): me my spouse 9. I believe that my request for physical custody is in the children's best interest because: 10. Write down your response to paragraphs 7 and 8 in the other party's Affidavit: 11. I am asking for (check one): supervised unsupervised parenting time for the children and my spouse because: 12. Write down your response to paragraph 9 in the other party's Affidavit: 13. I am asking for the parenting time schedule in my Responsive Motion and I believe this schedule is in the children's best interest because: American LegalNet, Inc. www.FormsWorkFlow.com DIV1103 State ENG Rev 10/17www.mncourts.gov/formsPage 3 of 414. If your parenting time schedule is different from the other party's, write down your response to paragraph 10 in the other party's Affidavit: 15. I am asking the Court to decide temporary child support:My monthly gross income is $ My spouse's monthly gross income is $ from from 16. I AM NOT asking for temporary spousal maintenance. I AM asking the Court to decide temporary spousal maintenance LATER. I AM asking the Court for spousal maintenance. I do not have enough income to meet my needs. My spouse has the income to meet his or her needs and is able to help me. My income and expenses are listed in the Affidavit. I need $ per month. I cannot support myself because: 17. Write down your response to paragraph 12 in the other party's Affidavit: 18. I am asking the Court to order my spouse to pay my attorney's fees: Yes No19. My spouse should go to an evaluation: Yes No20. Write down your response to paragraph 14 of the other party's Affidavit: 21. Check one I am asking the Court to order that I have sole use and possession of the homelocated at (full address): I am asking the Court to order my spouse have sole use and possession of our home located at (full address): I am asking the Court to order that my spouse and I share the use and possession ofour home located at (full address): I am asking the Court for the relief checked above because: American LegalNet, Inc. www.FormsWorkFlow.com DIV1103 State ENG Rev 10/17www.mncourts.gov/formsPage 4 of 422.Write down your response to paragraph 15 of the other party's Affidavit: 23.My spouse and I have already divided our personal belongings, household goods andfurniture (check one): Yes No24.My spouse and I own motor vehicle(s): Yes No25.My spouse and I have debts: Yes No26.I want to change certain medical, dental, automobile or life insurance policies: Yes No27.I am asking for insurance to be reinstated: Yes No28.I believe that my spouse's income will increase: Yes No29.I want the Court to order that my spouse shall not spend or otherwise use income raises,income tax refunds, bonuses or other extra income: Yes No30.I am asking the Court for permission to sell or otherwise get rid of other property: Yes No31.I asked the Court for additional relief: Yes NoI declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com