Free STATE OF MINNESOTA - Minnesota

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Judicial District: Court File Number: Case Type:
Dissolution without Children

In Re the Marriage of:
Name of Petitioner

Petitioner's Respondent's Application for Temporary Relief Without Children

and

Name of Respondent

STATE OF MINNESOTA COUNTY OF (County where Affidavit signed) My name is (check one): Petitioner

) ) SS )

and I state under oath that I am the Respondent in this case, and in this Application for I understand that

Temporary Relief, I will be referred to as the: Husband Wife.

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 years and the Husband's age is years.

.

The

2.

The parties have been separated Wife Husband has paid $

month(s), during which time: to the: Wife Husband.

3.

a. 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):

DIV604

State

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b. The wife has

nonjoint child(ren) from a previous marriage or relationship. per month for the support of the

The wife: pays receives $ nonjoint child(ren). c. The husband has

nonjoint child(ren) from a previous marriage or relationship. per month for the support of the

The husband: pays receives $ nonjoint child(ren). 4. The parties have the following assets: Description of Asset a. Car market value Balance due Year/Make b. Stocks, Bonds, Notes c. Cash and Savings d. Accounts Receivable e. Homestead/Real Estate 5. $ $ $ $ Wife uses or in wife's name $ $ /

Husband uses or in Husband's name $ $ / $ $ $ $

Both use or in both names $ $ / $ $ $ $

Secured debts (not including those listed above and not including homestead; attach additional sheets, if necessary): Name of Creditor Balance Due $ $ $ $ $ $ $ $ $ $ Monthly Payment Party Obligated Security Pledged

6.

Necessary Monthly Expenses (for you and the child(ren) if the child(ren) live with you): Monthly Expense a. Rent $ Wife/Husband Expenses Nonjoint Child(ren) Expenses $

DIV604

State

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Rev 1/09

www.courts.state.mn.us/forms

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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 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).

Wife

$

$

(2) Statutory Deductions

DIV604

State

ENG

Rev 1/09

www.courts.state.mn.us/forms

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Federal Income Tax State Income Tax Social Security, FICA, Medicare Pension Deduction Union Dues Dependent Health/Hospitalization 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) 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) (3) Unemployment/Worker's Comp. (4) Interest income per (5) Dividend income per (6) Gross rental income $ $ $ $ $ $ $ $ $ $ $ $

DIV604

State

ENG

Rev 1/09

www.courts.state.mn.us/forms

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(7) Other: 8. a. $ b. $ c. $ costs. 9. Additional Material Facts:

$

$

has been paid on wife's attorney's fees and costs. has been paid on husband's attorney's fees and costs. is reasonable for the: Wife's Husband's attorney's fees and

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

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