State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution without Children In Re the Marriage of: □ Petitioner’s □ Respondent’s Name of Petitioner Application for Temporary Relief Without Children and Name of Respondent STATE OF MINNESOTA ) ) SS ) COUNTY OF (County where Affidavit 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) years and the Husband’s age is Wife’s age is 2. The parties have been separated □ Wife □ Husband 3. . The years. month(s), during which time: has paid $ to the: a. The family home is: □ owned □ rented The family home is now occupied by: □ Wife □ Husband. by the parties. □ Wife □ Husband □ Both parties. Other person(s) live in the home (please specify): DIV604 State ENG Rev 1/09 www.courts.state.mn.us/forms Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com b. The wife has nonjoint child(ren) from a previous marriage or relationship. The wife: □ pays □ receives $ per month for the support of the nonjoint child(ren). nonjoint child(ren) from a previous marriage or relationship. c. The husband has The husband: □ pays □ receives $ per month for the support of the nonjoint child(ren). 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 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 a. Rent DIV604 Security Pledged $ $ Party Obligated State $ ENG Rev 1/09 www.courts.state.mn.us/forms Nonjoint Child(ren) Expenses $ Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 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. Home Maintenance $ $ t. Additional info (explain): $ $ TOTAL MONTHLY EXPENSES 7. $ $ $ Provide the following data for each employer. Attach paycheck stub(s) for the last month, or if available, the last three month(s): Husband Wife a. Name of Employer Type of Employment b. Income: (1) Gross Income per month $ $ (monthly income is to be calculated using a 4.3 multiple). (2) Statutory Deductions DIV604 State ENG Rev 1/09 www.courts.state.mn.us/forms Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com Federal Income Tax $ $ State Income Tax $ $ Social Security, FICA, Medicare $ $ Pension Deduction $ $ Union Dues $ $ Coverage $ $ Dental Coverage $ $ (3) Subtotal Statutory Deductions $ $ (4) Net Income (line 1 subtract line 3) (5) Other Pay Deductions (specify) $ $ $ $ (6) Subtotal Other Deductions $ $ (7) Net Take Home Pay (line 4 subtract line 6) $ $ $ $ $ $ $ $ $ $ (3) Unemployment/Worker’s Comp. $ $ (4) Interest income per $ $ (5) Dividend income per $ $ (6) Gross rental income $ $ Dependent Health/Hospitalization c. Tax withholding figures above are based on Married/Single taxpayer status with what number of deductions (for example; M-4, S-2): d. Employer reimbursed expenses Specify: e. Other income (1) Public Assistance (AFDC/GA) (2) Social Security Benefits for party or nonjoint child(ren) DIV604 State ENG Rev 1/09 www.courts.state.mn.us/forms Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com (7) Other: 8. $ $ 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. 9. Additional Material Facts: 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 DIV604 State ENG Rev 1/09 www.courts.state.mn.us/forms Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com