State of Minnesota District Court County □ □ Judicial District: Court File Number: Case Type: In Re the Marriage of:  Petitioner’s In Re the Custody of:  Respondent’s _____________ Parenting / Financial Disclosure Statement _____________ (Minn. Gen. R. Prac. 305) Name of Petitioner and Name of Respondent 1. Background Information Petitioner Respondent a. Full Name ________________________ ___________________ b. Age ________________________ ___________________ c. Years of Marriage (if applicable) Separation Date (if applicable) Present Mailing Address d. e. ___________________ ___________________ ___________________ ___________________ ___________________ 2. Court Order(s) Prohibiting Contact a. b. Is there an existing court order between you and the other party? (check all that apply) □ Harassment Restraining Order (HRO) □ Domestic Abuse Order for Protection (OFP) □ No Contact Order □ Other court order prohibiting contact with the other party: _________________ Have you been or are you now afraid of the other party? □ Yes □ No If yes, please explain: ___________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 7 3. Information Regarding The Minor Joint Children List the names, birth dates, and ages of the minor joint child(ren) of this legal action: Full Name of Child Birth Date Age a. Do any of the minor joint children have special needs? □ Yes □ No If yes, please explain: ___________________________________________________ b. Is there an agreement regarding parenting time? □ Yes □ No If yes, what is the parenting time arrangements for the child(ren)? ________________ c. Have you and the other party created a parenting plan? □ Yes □ No d. Is there an agreement regarding legal custody of the child(ren)? Legal custody means having a right to participate in the major decisions regarding the child’s life, including education, religious upbringing and medical treatment. □ Yes □ No If yes, what is the legal custody agreement? _________________________________ _____________________________________________________________________ e. Is there an agreement regarding physical custody of the child(ren)? Physical custody identifies who will handle the routine daily care and control of the child, and who the child will live with. □ Yes □ No If yes, what is the physical custody agreement? _______________________________ _____________________________________________________________________ f. If you have other nonjoint children, list first and last initials of each nonjoint child’s name, age and date of birth: _____________________________________________________________________ g. Is the wife now pregnant? □ NO □ YES, the due date is: _________ .(if applicable) h. Please indicate the name of the agency used for complying with the education requirement and the date scheduled or attended: _____________________________ 4. Employment and Income: a. Are you employed? □ Yes □ No If yes, where? Length of employment: American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 7 Monthly Income Received Salary and Wages (before deductions Amount $ Self-Employment Unemployment Benefits Commissions - Average Spousal Maintenance Received Bonus income - Average $ $ $ $ $ Monthly Income Received Social Security Received (social security disability, retirement, survivors’ benefit) Child’s Derivative Social Security or Veteran’s Benefits Workers’ Compensation Pension or Annuity Payments Military and Naval Retirement $ $ $ $ $ Other source of income (list source below) Supplemental Security $ (SSI) Total monthly income received: b. Amount $ $ Do you or the other party receive any child support for nonjoint childen? □ Yes □ No If Yes, state who receives it and how much per month: c. □ □ □ □ 5. Are you or the joint children currently receiving any form of public assistance? Yes (check all that apply) □ No Cash public assistance (MFIP) □ Food Stamps □ General Assistance Medical Assistance □ MinnesotaCare □ Child Care Subsidy Diversionary Work Program (DWP) □ TEFRA □ Other : d. If you checked any boxes above in 4c above, did you serve the County Attorney’s Office with a copy of your documents, as required? □ Yes □ No e. If you are not working, what is your source of income or support? Monthly Living Expenses Expense Type Rent / Mortgage Payment Cost $ Contract for Deed / 2nd Mortgage $ Homeowner’s / Rental $ Insurance Property Taxes (if not $ included in mortgage payment) Monthly Income Received Transportation (car payment, gasoline, bus, taxi Medical and Dental Expenses (not covered by insurance) Cable TV / Internet Amount Car Insurance $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 7 6. Heating & Electric Food $ $ Telephone / Cell Phone Child Care Payments Total monthly expenses: $ $ Clothing $ Other Spousal Maintenance $ payments Other Child support payments $ Other Miscellaneous payments $ Monthly Withholdings: a. Federal Income Tax Deductions $______________ b. State Tax Deductions: $ Social Security (FICA) and Medicare $______________ c. Retirement Contribution $______________ Union Dues $______________ Health Care / Medical $______________ Dental Coverage $______________ Other Paycheck Deductions (specify) ______________________ $______________ ______________________ $______________ d. Subtotal Deductions e. f. NET TAKE HOME PAY $______________ Tax withholding figures above are based on Married/Single taxpayer status with what number of deductions? (Example: M-4 or S-2) ____________________ Do you have medical and dental insurance coverage in place? □ Yes □ No If so, who is covered? __________________________________________________ g. $______________ Questions 7 through 11 apply only for marital dissolution actions. 7. Real Property: Provide the following information for real property owned by you and/or your spouse. If more room is needed, attach another sheet of paper labeled as Exhibit 7A. Homestead Other Property a. Date Acquired ____________ ________________ b. Purchase Price $___________ $ _______________ c. Present Fair Market Value $___________ $ _______________ d. Balance due on Mortgage $___________ $ _______________ e. Present Net Value (c – d) $___________ $ _______________ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 4 of 7 8. f. Monthly Payment (PITI) $___________ $ _______________ g. Rental Income, if any $___________ $ _______________ Personal Property: List the fair market value of the following personal property owned by you or your spouse: a. Checking, Savings Accounts (list) $_________________ $_________________ $_________________ b. c. d. e. Investment Accounts, Mutual Funds, Stocks, Bonds, etc. (list) __________________________________________ $_________________ __________________________________________ $_________________ IRAs, Profit Sharing Plans, Savings Plans (e.g. 401K), Pension, etc. __________________________________________ $_________________ __________________________________________ $_________________ Annuities __________________________________________ $_________________ __________________________________________ $_________________ Household goods and furnishings (including audio/video/computer) __________________________________________ f. g. h. $_________________ Vehicles, Boats, Campers, Snowmobiles, Aircraft, Trailer, etc.: __________________________________________ $_________________ __________________________________________ $_________________ __________________________________________ $_________________ __________________________________________ $_________________ Farm machinery, equipment, animals, crops, seed, etc.: __________________________________________ $_________________ __________________________________________ $_________________ __________________________________________ $_________________ Business or Partnership Interests __________________________________________ $_________________ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 5 of 7 i. Intellectual Property, such as patents, copyrights, etc. __________________________________________ j. Other __________________________________________ 9. $ ________________ $_________________ Nonmarital Claims Are you making any claim for nonmarital property? □ Yes □ No If yes, list items claimed as nonmarital below: Amount Claimed ___________________________________________________ $ __________________ 10. 11. ___________________________________________________ $ __________________ ___________________________________________________ $ __________________ Life Insurance: List all insurance policies owned by you and your spouse. Policy 1 Policy 2 Policy 3 Company ____________ ____________ _________ Type (Whole or Term) ____________ ____________ _________ Death Benefit $___________ $___________ $________ Cash Value $___________ $___________ $________ Loan Balance $___________ $___________ $________ Insured under the policy ____________ ____________ _________ Beneficiary ____________ ____________ _________ Owner of policy ____________ ____________ _________ Debts: List all debts not already listed in paragraph 7. If more room is needed, attach a schedule. Type of Debt (credit card, bank loan, etc.) Debt Owed To Minimum Monthly Payment Balance Due American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 6 of 7 Are you involved in any bankruptcy proceedings? Do you intend to file bankruptcy? □ Yes □ No □ Yes □ No 12. Documentary Information: Provide your three (3) most recent paystubs from your employment, your most recent Federal Tax Returns with all attachments, including W-2s and 1099s, and any statements from unemployment compensation, workers’ compensation, social security benefits statements, and all other documents evidencing earnings or income received during the last three months, including any public financial assistance in money or in-kind services (grants, heating assistance, rental assistance, etc.) NOTE: These documents contain your private information. To keep it private, fill out Confidential Financial Source Document (court form CON112) and use it as the cover page for your financial documents. See Minn. Gen. R. Prac. 11 for more information. The statements made by me in this Parenting / Financial Disclosure Statement are true and correct to the best of my knowledge. DATED: ________________________ ____________________________________ Signature of  Petitioner  Respondent ____________________________________ Signature of Attorney (if any) Attorney Name: _______________________ Address: ____________________________ City/State: ___________________________ Telephone: ( ) ____________________ E-mail address:_______________________ Attorney I.D.: ________________________ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15 www.mncourts.gov/forms Page 7 of 7