Free STATE OF MINNESOTA - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type: Dissolution

Select County
In Re the Marriage of:
Name of Petitioner

Affidavit in Support of Motion for Temporary Relief with Children

and

Name of Respondent

STATE OF MINNESOTA COUNTY OF My name is 1.

) ) SS ) and I state under oath that:

I am the (check one): Petitioner/Plaintiff Respondent/Defendant in this case, and I make this Affidavit in support of my Motion For Temporary Relief With Children.

2.

A juvenile court proceeding or child protection case involving any or all of the child(ren) in this case: IS NOT taking place in any county or state IS taking place in and the file number is County in the State of .

3.

An Order for Protection involving me and the other party and/or the child(ren): DOES NOT exist in any county or state

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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DOES exist in Order for Protection is dated

County in the State of and the file number is

.

The .

A copy of the Order for Protection is attached.

4.

My spouse and I have Full Name of Child (first, middle, last)

minor child(ren) who is/are: Date of Birth (mo/day/year)

Age

5.

The child(ren) currently live with: Petitioner/Plaintiff Respondent/Defendant Other who is the child(ren)'s: Mother Father Other relation to the children. in , State of , zip code . the The

The address of the child(ren) is City of

child(ren) has/have lived at this address since the date

6.

I want the Court to grant temporary legal custody of the child(ren): (check one) a. Jointly to me and my spouse because

b. Solely to (check one): Me My spouse because

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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7.

I want the Court to grant temporary physical custody of the child(ren) (check one): a. Jointly to me and my spouse, with the child(ren) living with me at the following times:

and the children living with my spouse at the following times

b. Solely to: Me 8.

My spouse

I believe that my request for physical custody is in the child(ren)'s best interests because

9.

I am asking for (check one):

supervised

unsupervised

parenting time for the

child(ren) and my spouse because

10.

I am asking for the parenting time schedule in my Motion and I believe this schedule is in the child(ren)'s best interests because

11.

I am asking the Court to decide temporary child support.

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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My monthly gross income is $ My spouse's monthly gross income is $

from from

12.

I AM NOT asking for temporary spousal maintenance. I AM asking the Court to decide temporary spousal maintenance LATER. I AM asking the Court for spousal maintenance. I do not have enough income to meet my needs. My spouse has income to meet his or her needs and is able to help me. My income and expenses are in my Application for Temporary Relief. I need $ per month. I cannot support myself because

13.

I am asking the Court to order my spouse to pay my attorney's fees: YES NO. YES, I need attorney's fees because

If

14.

My spouse should go to an evaluation: YES NO. If YES, the evaluations should be ordered for: (check all that apply) Alcohol use Drug use Anger management/Domestic abuse or Other (please specify)

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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15.

I am asking the Court to order that I have sole use and possession of our home located at (the address)

I am asking the Court to order that my spouse have sole use and possession of our home located at (the address)

I am asking the Court to order that my spouse and I stay in the home located at (the address)

I am asking the Court for the relief checked above because

16.

My spouse and I have already divided our personal belongings, household goods and furniture: (check one): YES NO. If NO, I am asking for the temporary use and possession of the following personal property, household goods and furniture (list the specific items):

because

I am asking that my spouse have the temporary use and possession of the following household goods and furniture (list the specific items):

because

17.

My spouse and I own motor vehicle(s): YES NO. If YES, I want the temporary use and possession of the following motor vehicle(s): (list year/make/model for each vehicle) because

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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I want my spouse to have the temporary use and possession of the following motor vehicle(s): (list year/make/model for each vehicle)

because

I will make the payments and insurance costs for my vehicle(s): YES NO. no, I want my spouse to make these payments because

If

My spouse should make the payments and insurance costs for his/her vehicle(s): YES NO. If NO, I want my spouse to make these payments because

18.

My spouse and I have debts: YES NO. If YES, I am asking the Court to order the debts to be paid temporarily as I asked in my Motion because

19.

I want to change certain medical, dental, automobile or life insurance policies: YES NO. If YES, I want to make the following changes:

because

20.

I am asking for insurance to be reinstated: YES NO. a. b. c. What insurance has lapsed or been cancelled: The date that the insurance lapsed or was cancelled: Who let the insurance lapse or cancelled it:

If YES, explain:

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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d.

Why should the insurance be reinstated:

21.

I believe that my spouse's income will increase: YES NO.

If YES, this income is

(check all that apply): salary or wage increases; overtime pay; bonuses; or other (specify: I want the Court to order my spouse to immediately notify me of any changes in his or her income: YES NO because (s)he might not tell me and I want to know because

22.

I want the Court to order that my spouse shall not spend or otherwise use income raises, income tax refunds, bonuses or other extra income: YES NO. If YES, because

23.

I am asking the Court for permission to sell or otherwise dispose of property: YES NO. (be specific): If YES, I want to sell or otherwise dispose of the following property

because

24.

I asked the Court for additional relief: YES NO.

I asked for this relief because

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

Page 7 of 8

Dated:
Signature (Sign only in front of notary public or court administrator.)

Name: Sworn/affirmed before me this day of , . Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator

DIV1003

State

ENG

Rev 1/07

www.mncourts.gov/forms

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