State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution with Children In Re the Marriage of: Petitioner’s Name of Petitioner Respondent’s Application for Temporary Relief With Children and Name of Respondent STATE OF MINNESOTA ) ) SS ) COUNTY OF (County where Application signed) My name is (check one): and I state under oath that I am the Petitioner Respondent in this case, and in this Application for Temporary Relief, I will be referred to as the: Husband Wife. I understand that as I fill out this Application for Temporary Relief, I am under oath and must tell the truth. 1. The parties were married on (month/day/year) Wife’s age is 2. 3. DIV1004 years and the Husband’s age is The parties have been separated Wife . Husband has paid $ The years. month(s), during which time: to the: Wife Husband. a. During the marriage, the following joint child(ren) were born to or adopted by the parties: Child’s Address Child’s Full Name Date of Birth Lives With (Street Address, City, (first, middle, last) State, Zip Code) State ENG Rev 1/09 www.mncourts.gov/forms Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com b. The family home is: owned rented The family home is now occupied by: by the parties. Wife Husband Both parties. Other person(s) live in the home (please specify): c. It is in the best interests of the joint child(ren) that the joint child(ren) be in the physical custody of the wife husband both parties because (specifically explain your reasons) nonjoint child(ren) from a previous marriage or relationship. d. The wife has The wife: Ƒ pays Ƒ receives $ per month for the support of the nonjoint child(ren). These nonjoint children Ƒ do Ƒ do not live with the wife. e. The husband has The husband: nonjoint child(ren) from a previous marriage or relationship. pays receives $ per month for the support of the nonjoint child(ren). These nonjoint children Ƒ do Ƒ do not live with the husband. 4. The parties have the following assets: Description of Asset Wife uses or in wife’s name a. Car market value $ Balance due $ Year/Make Husband uses or in Husband’s name $ $ / Both use or in both names $ $ / / b. Stocks, Bonds, Notes $ $ c. Cash and Savings $ $ $ d. Accounts Receivable $ $ $ e. Homestead/Real Estate DIV1004 $ $ $ $ State ENG Rev 1/09 www.mncourts.gov/forms Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 5. Secured debts (not including those listed above and not including homestead; attach additional sheets, if necessary): Name of Creditor Monthly Payment Balance Due $ $ $ $ $ 6. $ $ $ Necessary Monthly Expenses (for you and the child(ren) if the child(ren) live with you): Wife/Husband Expenses Monthly Expense Child(ren) Expenses a. Rent $ $ b. Mortgage payment $ $ c. Contract for Deed payment $ $ d. Homeowner’s insurance $ $ e. Real Estate taxes $ $ f. Utilities $ $ g. Heat $ $ h. Food $ $ i. Clothing $ $ j. Laundry and Dry Cleaning $ $ k. Medical and Dental $ $ l. Transportation $ $ m. Car Insurance $ $ n. Life Insurance $ $ o. Recreation/Travel $ $ p. Newspapers/Magazines $ $ q. Social, Church obligations $ $ r. Personal Allowances/Incidentals $ $ s. Babysitting and Day Care DIV1004 Security Pledged $ $ Party Obligated $ $ State ENG Rev 1/09 www.mncourts.gov/forms Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com t. Home Maintenance $ $ u. Child(ren)’s School Needs $ $ v. Child(ren)’s Allowances $ $ w. Additional info (explain): $ $ $ $ $ $ $ $ TOTAL MONTHLY EXPENSES 7. My gross monthly income is $ from My spouse’s gross monthly income is $ from I have filed a Financial Affidavit for Child Support with the court, containing my gross income and required proof such as pay stubs or tax returns. 8. a. $ per month is a reasonable amount to be paid by me for temporary (number of) joint child(ren). support for b. $ per month is a reasonable amount to be paid to me for temporary support for c. $ (number of) joint child(ren). per month is a reasonable amount to be paid to me for temporary spousal maintenance. d. Payment should be made on the first (1st) and fifteenth (15th) of each month starting on (month, day, year) 9. . a. $ has been paid on wife’s attorney’s fees and costs. b. $ has been paid on husband’s attorney’s fees and costs. c. $ is reasonable for the: Wife’s Husband’s attorney’s fees and costs. 10. DIV1004 Additional Material Facts: State ENG Rev 1/09 www.mncourts.gov/forms Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com Based upon the above information, I ask the Court for an Order granting such relief prior to trial as may be just and lawful. Dated: Signature of: Petitioner Respondent (Sign only in front of notary public or court administrator.) Name: Subscribed and sworn to before me this day of , . Address: City/State/Zip: Telephone: Notary Public \ Deputy Court Administrator DIV1004 State ENG Rev 1/09 www.mncourts.gov/forms Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com