FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 7State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: In Re the Marriage of: In Re the Custody of: Name of Petitioner (first, middle, last) and Name of Respondent (first, middle, last) Petitioner's Respondent'sParenting / Financial Disclosure Statement (Minn. Gen. R. Prac. 305)1. Background InformationPetitionerRespondenta. Full Name b. Age c. Years of Marriage (if applicable) d. Separation Date (if applicable) e. Present Mailing Address 2. Court Order(s) Prohibiting Contact a. 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: b. Have you been or are you now afraid of the other party? Yes No American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 73. Information Regarding The Minor Joint Children List the names, birth dates, and ages of the minor joint children of this legal action:Full Name of ChildBirth DateAge a. Do any of the minor joint children have special needs? Yes No b. Is there an agreement regarding parenting time? Yes No c. Have you and the other party created a parenting plan? Yes No d. Is there an agreement regarding legal custody of the children? 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 e. Is there an agreement regarding physical custody of the children? Physical custody identifies who will handle the routine daily care and control of the child, and who the child will live with. Yes No f. If you have other non-joint children, list first and last initials of each non-joint child's name, age and date of birth: g. Is the wife now pregnant? No Yes, the due date is: 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 b. Do you or the other party receive any child support for non-joint children? Yes No c. Are you or the joint children currently receiving any form of public assistance? American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 3 of 7 Yes (check all that apply) No 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? 5. Monthly Living Expenses Expense Type Cost Expense Type Cost Rent / Mortgage Payment $ Transportation (car payment, gasoline, bus, taxi) $ Contract for Deed / 2nd Mortgage $ Medical and Dental Expenses (not covered by insurance) $ Homeowner's / Rental Insurance $ Cable TV / Internet $ Property Taxes (if not included in mortgage payment) $ Car Insurance $ Heating & Electric $ Clothing $ Food $ Other Spousal Maintenance payments $ Telephone / Cell Phone $ Other Child support payments $ Child Care Payments $ Other Miscellaneous payments $ Total monthly expenses: $ 6. Monthly Withholdings: a. Federal Income Tax Deductions $ b. State Tax Deductions $ Social Security (FICA) and Medicare $ Retirement Contribution $ Union Dues $ Health Care / Medical $ Dental Coverage $ c. Other Paycheck Deductions (specify) $ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 4 of 7 $ $ d. Subtotal Deductions $0 e. NET TAKE HOME PAY $ f. Tax withholding figures above are based on Married/Single taxpayer status with what number of deductions? (Example: M-4 or S-2) g. Do you have medical and dental insurance coverage in place? Yes NoQuestions 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. HomesteadOther Property a. Date Acquired b. Purchase Price $ $ c. Present Fair Market Value $ $ d. Balance due on Mortgage $ $ e. Present New Value (c-d) $ $ f. Monthly Payment (PITI) $ $ g. Rental Income, if any $ $8. Personal Property: List the fair market value of the following personal property owned by your or your spouse: a. Checking, Savings Accounts (list) $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 5 of 7 b. Investment Accounts, Mutual Funds, Stocks, Bonds, etc. (list) $ $ $ $ c. IRAs, Profit Sharing Plans, Savings Plans (e.g. 401K), Pension, etc. $ $ $ $ d. Annuities $ $ e. Household goods and furnishing (including audio/video/computer) $ $ $ $ f. Vehicles, Boats, Campers, Snowmobiles, Aircraft, Trailer, etc.: $ $ $ $ $ g. Farm machinery, equipment, animals, crops, seed, etc.: $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 6 of 7 h. Business or Partnership Interests $ $ $ i. Intellectual Property, such as patents, copyrights, etc. $ j. Other $9. Non-marital Claims Are you making any claim for non-marital property? Yes No10. Life Insurance: List all insurance policies owned by you and your spouse.Policy 1Policy 2Policy 3 Company Type (Whole or Term) Death Benefit $ $ $ Cash Value $ $ $ Loan Balance $ $ $ Insured under the policy Beneficiary Owner of Policy 11. Debts: List all debts not already listed in paragraph 7. If more room is needed, attach a schedule.Type of Debt (credit care, bank loan, etc.)Debt Owed ToMinimum Monthly PaymentBalance Due $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com FAM108 State ENG Rev 7/15www.mncourts.gov/formsPage 7 of 7Type of Debt (credit care, bank loan, etc.)Debt Owed ToMinimum Monthly PaymentBalance Due $ $ $ $Are you involved in bankruptcy proceedings? Yes NoDo you intend to file bankruptcy? Yes No12.Documentary Information: Provide your three (3) most recent paystubs from youremployment, your most recent Federal Tax Returns with all attachments, including W-2sand 1099s, and any statements from unemployment compensation, workers' compensation,social security benefits statements, and all other documents evidencing earnings or incomereceived during the last three months, including any public financial assistance in money orin-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 ID: Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com