State of Minnesota District Court County Judicial District: Court File Number: Case Type: Dissolution In Re the Marriage of: Name of Petitioner † Petitioner’s † Respondent’s Prehearing Statement vs. Name of Respondent 1. Personal Information a. Full Name Husband ________________________ Wife _________________________ b. Present Mailing Address ________________________ _________________________ ________________________ _________________________ c. Employer Name ________________________ _________________________ d. Employer Street Address ________________________ _________________________ City, State, Zip ________________________ _________________________ e. Birthdate ________________________ _________________________ f. Marriage Date ________________________ g. Separation Date (Different Residences)___________________________________________ h. Date(s) of Temporary Order(s) (if any) ___________________________________________ i. Minor child(ren) of this marriage or who will be affected by this legal action are: Full Name of Child DIV105 State ENG Rev 5/08-D Date of Birth www.mncourts.gov/forms Age Living With Page 1 of 8 American LegalNet, Inc. www.FormsWorkflow.com j. Is the wife now pregnant? † NO † YES, the due date is: _______________________. k. Is the issue of legal or physical custody contested? † NO † YES. If custody is disputed, each party shall submit proposals for custody and parenting time for each child as Exhibit 1A. 2. EMPLOYMENT: Provide the following data for each employer. Attach prior month(s) paycheck stub(s) as Exhibit 2A. b. Name of Employer Wife _________________________ Length of Employment a. Husband ________________________ ________________________ _________________________ Income: (1) Gross Income per Month (Monthly income is to be calculated using a 4.3 multiple) $ _____________ $ ________________ (2) Statutory Deductions: Federal Income Tax $ _____________ $ ________________ State Withholding $ _____________ $ ________________ Social Security (FICA) and Medicare $ _____________ $ ________________ Pension Deduction $ _____________ $ ________________ Union Dues $ _____________ $ ________________ Hospitalization Coverage $ _____________ $ ________________ Dental Coverage $ _____________ $ ________________ (3) Subtotal Statutory Deductions $ _____________ $ ________________ (4) Net Income $ _____________ $ ________________ (line 1 subtract line 3) $ _____________ $ ________________ ______________________ $ _____________ $ ________________ ______________________ $ _____________ $ ________________ (6) Subtotal Other Deductions $ _____________ $ ________________ (7) NET TAKE HOME PAY (line 4 subtract line 6) $ _____________ $ _____________ $ ________________ $ ________________ Dependent Health/ (5) c. DIV105 Other Paycheck Deductions (specify) Tax withholding figures above are based on Married/Single taxpayer status with what number of State ENG Rev 5/08-D www.mncourts.gov/forms Page 2 of 8 American LegalNet, Inc. www.FormsWorkflow.com deductions? (Example: M-4 or S-2) d. e. ______________ Will your medical and dental insurance coverage be available for your spouse and children after the dissolution? _________________ † YES † NO $ _____________ $ ________________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ _____________ $ ________________ ____________________________ f. Other Income: (1) Public Assistance (AFDC/GA) (2) Social Security Benefits for party or child(ren) (3) Unemployment/Workers Comp. (4) Interest paid per _____________ (5) Dividend paid per ___________ (6) Gross Rental Income (7) Other Income (specify): ____________________________ $ _____________ $ ________________ List all employment benefits received, including but not limited to bonuses paid or due, automobile or travel expense reimbursement, other per diem compensation, and memberships paid by the employer: Petitioner: __________________________________________________________________ __________________________________________________________________________ Respondent: ________________________________________________________________ __________________________________________________________________________ 3. CHILD SUPPORT/SPOUSAL MAINTENANCE: a. As a result of a different case, Petitioner (check one): (check one or both): † child support † pays † receives † maintenance. If an amount is paid or received, the amount paid/received each month for child support is $ and for maintenance is $ according to the Order issued in County, dated and there (check one): † is not an arrearage b. † is an arrearage in the amount of $ As a result of a different case, Respondent (check one): (check one or both): † child support † pays . † receives † maintenance If an amount is paid or received, the amount paid/received each month for child support is $ DIV105 State and for maintenance is $ ENG Rev 5/08-D according to the Order www.mncourts.gov/forms Page 3 of 8 American LegalNet, Inc. www.FormsWorkflow.com issued in County, dated and (check one): † is not an arrearage † is an arrearage in the amount of $ c. In this proceeding a temporary order (check one): † has not been issued there . † has been issued and includes an order for: (1) † Child support to be paid by (check one): † Petitioner per month and there (check one): in the amount of $ † is not an arrearage † Respondent † is an arrearage of $ . (2) † Maintenance to be paid by (check one): † Petitioner † Respondent per month and there (check one): in the amount of $ † is not an arrearage 4. † is an arrearage of $ . LIVING EXPENSES: List your necessary monthly 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 (includes $ m. Car Insurance $ ________________ n. Life Insurance $ ________________ o. Recreation, Entertainment and Travel $ ________________ p. Newspapers and Magazines $ ________________ q. Social and Church Obligation $ ________________ r. Personal Allowances and Incidentals $ ________________ s. Babysitting and Day Care $ ________________ t. Home Maintenance $ ________________ DIV105 State ENG Rev 5/08-D car payment) $ ________________ www.mncourts.gov/forms Page 4 of 8 American LegalNet, Inc. www.FormsWorkflow.com u. Child(ren)’s School Needs/Allowances v. $ ________________ Additional expenses (specify) _________________________ TOTAL MONTHLY EXPENSES: 5. $ ________________ $ ________________ 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 5A. Homestead Other Property a. ___________ $_______________ b. Purchase Price $ __________ $_______________ c. Present Fair Market Value $ __________ $_______________ d. First Mortgage Balance $ __________ $_______________ e. Second Mortgage Balance or Home Improvement Loan $ __________ $_______________ f. Net Value $ __________ $_______________ g. Monthly Payment (PITI) $ __________ $_______________ h. Rental Income, if any $ __________ $_______________ i. 6. Date Acquired Title in name(s) of ___________ ________________ PERSONAL PROPERTY: List the fair market value of the following person property: In Name or Possession of Husband Wife Both $ __________ $ __________ $ __________ _______________________ $ __________ $ __________ $ __________ _______________________ $ __________ $ __________ $ __________ _______________________ $ __________ $ __________ $ __________ _______________________ $ __________ $ __________ $ __________ a. Household contents b. Stocks, Bonds, etc. (list) c. d. DIV105 Checking Accounts (list) Receivables and Claims (list State ENG Rev 5/08-D www.mncourts.gov/forms Page 5 of 8 American LegalNet, Inc. www.FormsWorkflow.com _______________________ $ __________ $ __________ $ __________ (2)Make/Model/Year (3)Make/Model/Year ___________ ___________ ___________ Market Value $ __________ $ __________ $ __________ Encumbrance $ __________ $ __________ $ __________ Net Value $ __________ $ __________ $ __________ Monthly Payment $ __________ $ __________ $ __________ In possession of ___________ ___________ ___________ (1)Make/Model/Year (2)Make/Model/Year (3)Make/Model/Year ___________ ___________ ___________ Market Value $ __________ $ __________ $ __________ Encumbrance $ __________ $ __________ $ __________ Net Value $ __________ $ __________ $ __________ Monthly Payment $ __________ $ __________ $ __________ In possession of g. $ __________ (1)Make/Model/Year f. $ __________ _______________________ e. $ __________ ___________ ___________ ___________ Motor Vehicles (cars, trucks, vans): Boats, Motors, Campers, Snowmobiles, Trailer, etc.: Other (such as power equipment, tools, guns, valuable animals, etc.): (1) Description (3) Description Market Value $ __________ $ __________ $ __________ Encumbrance $ __________ $ __________ $ __________ Net Value $ __________ $ __________ $ __________ In possession of 7. (2) Description ___________ ___________ ___________ NONMARITAL CLAIMS: List all items you claim are your nonmarital property. Items Claimed as Nonmarital Value ___________________________________________________ $________________________ ___________________________________________________ $________________________ ___________________________________________________ $________________________ ___________________________________________________ $________________________ DIV105 State ENG Rev 5/08-D www.mncourts.gov/forms Page 6 of 8 American LegalNet, Inc. www.FormsWorkflow.com 8. LIFE INSURANCE: List all insurance policies owned by you and your spouse. Policy 1 Policy 3 Company ___________ ___________ ___________ Policy Number ___________ ___________ ___________ Type (Whole or Term) ___________ ___________ ___________ Face Amount $ __________ $ __________ $ __________ Cash Value $ __________ $ __________ $ __________ Loan Balance $ __________ $ __________ $ __________ Insured ___________ ___________ ___________ Beneficiary ___________ ___________ ___________ Owner ___________ ___________ ___________ Husband Wife Present Cash Value $ __________ $ __________ Vested or Nonvested ___________ ___________ Present Cash Value $ __________ $ __________ c. Deferred Compensation $ __________ $ __________ d. 9. Policy 2 Military Pension or Disability $ __________ $ __________ PENSION PLAN AND/OR PROFIT-SHARING PLAN: a. b. Plans Through Employment: Private Plans (IRA, Keogh, SEP, etc.) 10. DEBTS: List all debts not already listed in paragraphs 4 or 5. If more room is needed, attach a schedule for secured debts labeled as Exhibit 10A and a schedule for unsecured debts labeled as Exhibit 10B. a. Secured Debts Debt 2 Debt 3 Creditor ___________ ___________ ___________ Balance Due $ __________ $ __________ $ __________ When Incurred DIV105 Debt 1 ___________ ___________ ___________ State ENG Rev 5/08-D www.mncourts.gov/forms Page 7 of 8 American LegalNet, Inc. www.FormsWorkflow.com Party Obligated ___________ ___________ ___________ Reason for Debt ___________ ___________ ___________ Total Secured Debt: b. Husband$ _________ Wife$___________ Joint$ ___________ Unsecured Debts Debt 1 Debt 2 Debt 3 Creditor ___________ ___________ ___________ Balance Due $ __________ $ __________ $ When Incurred ___________ ___________ ___________ Party Obligated ___________ ___________ ___________ Reason for Debt ___________ ___________ ___________ Total Unsecured Debt: Husband$ _________ Wife$___________ Joint$ ___________ The statements made by me in this Prehearing 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: Attorney I.D.: ______________________________ DIV105 State ENG Rev 5/08-D www.mncourts.gov/forms Page 8 of 8 American LegalNet, Inc. www.FormsWorkflow.com