Preview
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
magma. Coufig
533:3 w: {agilnnasaa
State of Minnesota District Court
County of: mac: m -
.3 Bdiéiamgmcc Em WM
Court File Number: &7‘ E A ‘
)q‘uq ‘ 5
Hmw t(fl
Case Type: Dissoiution with Children
In Re the Marriage of:
Meghann, Michelle, Lawrence Joint Petition, Agreement, and
Name of Petitioner A (first, middle’ 1a“) Judgment and Decree for Marriage
and Dissolution With Children
Steven, Francis, Lawrence
Name of Petitioner B (first, m (idle, last)
1.Information about Petitioner A:
Full Name: Meghann Michelle Lawrence
First Middle Last
Address: 41 17 Meadowbrook Lane
Street Address Apt. No.
St. Louis Park Hennepin MN 55426
City County State Zip Code
Date of Birth: 1 1/23/1 977
Petitioner A's former or other names 01'write "None“:
Meghann Michelle Rezabek
First Middle Last
First Middle Last
Petitioner A's social securiqy number is listedon Confidential Form 11.1 and submitted along
with the Joint Petition.
2.Information about Petitioner B:
Full Name: Steven Francis Lawrence
First Middle Last
Address: 5400 West 70th Street 308
Street Address Apt. No.
DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 1 0f49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
Edina Hennepin MN 55439
City County State Zip Code
Date of Birth: 08/1 8/1 979
M".
Petitioner B's former or other names or write "None .
NONE
First Middle Last
First Middle Last
Petitioner B's social security number is Iisted on Confidential Form and submitted aiong
I 1.},
with the Joint Petition.
3. Our Marriage
Petitioners were married on (month, day, year) 03, 7,2008
in the City of Grand Forks ,County of Grand Forks ,
State of North Dakota ,Country of USA
4. 180 Day Requirement
a. Petitioner A has been living in Minnesota for the past six (6) months: © YES O NO
b. Petitioner B has been living in Minnesota for the past six (6) months: ® YES O NO
c. Petitioners were married in Minnesota, but neither Petitioner A nor O YES © NO
Petitioner B reside in Minnesota, nor reside in ajurisdiction that will
maintain an action for dissolution because of the sex or sexual
orientation of the Petitioners.
5. Armed Forces
a. Petitioner A is an active duty member of the armed forces: O YES © NO
IF YES, has the member of the armed forces been stationed inMinnesota
for the past six (6) months? O YES O NO
b. Petitioner B is an active duty member of the armed forces: O YES © NO
IF YES, has the member of the armed forces been stationed inMinnesota
months?
for the past six (6) O YES O NO
6. Marriage Cannot be Saved
There has been an irren‘ievable breakdown of our marriage relationship.
7. Physical Living Situation
Do the Petitioner A and Petitioner B live together at this time? O YES ® NO
If NO, the date we separated was: 11/02/201 8
0N1 702 State ENG Rev 5/19 www.mncourtsgovlfon'ns Page 2 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
If YES, Petitioner A and Petitioner B are living together at this time because:
8. Other Proceedings
a.Has a separate court case for marriage dissolution, legal separation, O YES © NO
custody, paternity or annulment already been started by Petitioner A
or Petitioner B in Minnesota or elsewhere?
If YES, the type of court case is
and itwas started in County,
in the State of , and the court file number is
and the status or outcome of the case is: O Open O Closed O Unknown
01'
b.Has a County started a Support case involving the Petitioner A and O YES © N0
the Petitioner B or their chiidren?
If YES, the case was started in County,
in the State of and the- court file number is
h
The case D has been Dismissed fl isPending Q resulted with an Order for Support.
9. Protection or Harassment Order
a.An Orderfor Protection or a Harassment/Restraining Order in O YES © NO
efiect regarding Petitioner A and Petitioner B:
If YES, the Order protects: D Petitioner A [j Petitioner B [:1 the children
The Order was filed in County, on the date; ,
and the court file number is .A copy of the Order is submitted with
this Joint Petition.
b. If an Orderfor Protection isin effect, docs the Orderfbr O YES O NO
Protection include a child support obligation?
10. Child Protection Case
a.Has a child protection case invoiving Petitioner A and Petitioner B's O YES © NO
children taken place in Minnesota or another state?
If YES, the case is in County,
DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 3 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
in the State 0f and the court file number is
The name of the child or chiidren involved in the child protection case is:
11. Children Petitioner A and Petitioner B have Together (Joint Children)
"Child" means a living person under the age 18, or under age 20 and stillin high school.
a.List all joint children born before the marriage or born or adopted during the marriage. If
there are no joint children, or if a spouse is not currently pregnant, yon are using the
wrong form. Use Joint Petition, Agreement and Judgment and Decree Without Children.
Fun Name or Child ”gig Age Chad Currently Lives With
O Petitioner A O Petitioner B
@ Both parents
StellaJune Lawrence 01/1 2/201 O 9 OR
(write in name)
O Petitioner A O Petitioner B
G 'eyson E ”gene
© Both parents
Lawrence
12/02/201 3 5 0R
(wn'te in name)
O Petitioner A O Petitioner B
O Both parents
OR
(write in name)
O Petitioner A O Petitioner B
O Both parents
OR
(write in name)
O Petitioner A O Petitioner B
O Both parents
OR
(write in name)
DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 4 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
The social security number of the children are listed on Confidential Form 11.1 and
submitted along with the Joint Petition.
If a child is Iiving with someone other than a parent, write the child's address below:
Address :
Street Address Apt. No‘
City County State Zip Code
b. Has each child born to or adopted by Petitioner A and Petitioner B © YES O NO
together lived in Minnesota for the past six (6) months?
If NO, name the child or children, name the State(s) the child has lived in during the past 6
months, and the dates the chiid lived in each state:
12. Adult Dependent Children: Child support may be ordered for a joint child over the age of
18 who cannot support him/herself because of a physical or mental condition.
a. Isthere an adult joint child born to or adopted by Petitioner A and O YES <9 N0
Petitioner B who is not able to support himfhcrself because of a
physical or mental condition?
If YES, the fun name, daze of birth and age of each adult dependent is:
Full Name of Dependent Date of Birth Age
The social scourity number of the adult dependent children are listed on Confidential Form
11.1 and submitted along with the Petition.
l3. Pregnancy
a. IsPetitioner A pregnant? O YES © NO
If Petitioner A is pregnant, answer (i) and (ii):
(i)The date the baby is due is
(ii)Do Petitioner B and Petitioner A agree that Petitioner B is the O YES O NO
biological father of the unborn child?
IfNO, D Petitioner B D Petitioner A claims Petitioner B is not the biological father
of the child.
DIV1 702 State ENG Rev 5/19 wmmmncourtsgovlfonns Page 5 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
b. Is Petitioner B pregnant? O YES © NO
14. Petitioner A's Children from Other Relationship (Non-joint Children)
a.Does Petitioner A have minor children born prior to the marriage O YES © NO
fi'om another marriage or relationship?
b. Has Petitioner A given binh during the marriage to a minor child OYES © NO
who isnot a chiid of Petitioner B?
If YES, answer and (iv):
(i), (ii), (iii)
(i).List the full name, dase of birth and age of each child born to Petitioner A since
marrying Petitioner B, who is not a child of Petitioner B:
ls Pemmne' A CW?“
Fun Name or Child and Date of Does Child Live with
ordered to pay Child
A ge Birth Petitioner A"'
Support for this Child?
OYES 0N0 oYEs 0N0
oYEs ONO oYEs 0N0
oYEs 0N0 oYEs 0N0
oYEs 0N0 oYEs 0N0
QYES 0N0 oYEs 0N0
(ii) Isthere a Court Order naming someone other than O YES O N0
Petitioner B as the father of the children listed in
(i) above?
If YES, attach a copy of the Order. The Order is for:
Full Name of children
(iii)Have Petitioner A and biological father signed a O YES O N0
Minnesota Recognition of Parentage (ROP) for
any of the children fisted in (i) above?
If YES, state the name of the child:
Full Name of Children
and attach a copy of the Recognition of Parentagc.
If NO, why not?
(iv) Has Petitioner B signed the "Spouse's NOn— O YES O NO
Parentage Statement" for any of the. children
listed at (i)above?
DIV‘! 702 State ENG Rev 5/1 9 wmvmncourtsgov/forms Page 6 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
If YES, state the name of the child:
and submit a copy of the "Spouse's Non-Parentage Statement."
If NO, why not?
15. Petitioner B's Children from Other Relationship (Non—joint Children)
a. Does Petitioner B have minor children born prior to the marriage from O YES ® NO
another marriage or relationship?
If YES, the full name, date of birth and age of each child born prior to the marriage is:
Is Pet‘mne' B CWT"
Fun Name of Child and Date of Does Child Live with
ordered to pay Chad
Age Birth Petitioner B"°
Support for this Child?
O YES O NO O YES O N0
OYES ONO OYES ONO
OYES ONO OYES ONO
OYES ONO OYES ONO
OYES ONO OYES ONO
b. Has Petitioner B given birth during the marriage to a minor child who is O YES © N0
not a child of Petitioner A?
If YES, answer and
(i), (ii), (iii) (iv):
(i).List the fun name, date of birth and age of each child born to Petitioner B since
marrying Petitioner A, who is not a child of the Petitioner A:
Fun Name of Child and Date of Does Child Live with
Is Pam“ B CWT"
ordered t” Pay Chad
Age Birth Petitioner B?'
Support for this Child?
oYEs 0N0 OYES 0N0
oYBs ONO oYEs 0N0
o YES ONO OYES 0N0
QYEs 0N0 oYEs 0N0
OYES 0N0 QYES 0N0
(ii) Is there a Court Order naming someone other than Petitioner A O YES O N0
as the father of the children listed in (i) above?
If YES, submit a copy of the Order. The Order is for:
DIV1 702 State ENG Rev 5/19 www.mncourtsgovfforms Page 7 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
Fufl Name of children
(iii)Have Petitioner B and biological father signed a Minnesota O YES O N0
Recognition of Parentage (ROP) for any of the children Iisted
in (i)above?
If YES, state the name of the child:
Full Name of Children
and attach a copy of the Recognition of Parentage.
If NO, why not?
(iv) Has Petitioner A signed the "Spouse's Non-Parentage O YES O N0
Statement" for any of the children listed at (i)above?
If YES, state the name of the child:
and submit a copy of the "Spouse's Non—Parentage Statement."
If NO, why not?
16. Custody
It isin the child’s best interests and we agree that legal custody be granted as follows:
(check one)
© Joint legal custody to both parents
O Sole legai custody to O Petitioner A O Petitioner B
It isin the child's best interests and we agree that physical custody be granted as follows:
(check one)
© Joint physical custody to both parents
O Sole physical custody t0 O PetitioncrA O Petitioner B
17. Parenting Time
Petitioner A's parenting time with the joint children should be: (check one)
If parenting time is unsupervised for both parents, skip to Question 18.
© unsupervised O supervised O reserved
For supervised parenting time answer a and b. For reserved parenting time, answer c.
DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 8 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
(Option 1) Supervision isnecessary because unsupervised parenting time islikely to
endanger the child's physical or emotional health or impair the child's emotional
development. The circumstances supporting this finding are:
(Option 2) We agree that supervised parenting time is necessary because
It isin the best interests of the children that Petitioner A's parenting time be supervised as
follows: (State who should supervise the parenting time, and if there isa cost involved, who
should pay the cost and any other important details)
c.We agree that Petitioner A‘s parenting time should be reserved because:
Petitioner B's parenting time with the joint children should be: (check one)
© unsupervised O supervised O reserved
For supervised parenting time answer a and b. For reserved parenting time, answer c.
DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 9 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
(Option .1) Supervision isnecessary because unsupervised parenting time islikely to
endanger the chiid‘s physical or emotional health or impair the child's emotional
development. The circumstances supporting this finding are:
(Option 2) We agree that supervised patenting time is necessaly because
b. It is in the best interestsof the children that Petitioner B's parenting time be supervised as
follows: (State who should supervise the parenting time, and if there is a cost involved,
who should pay the cost and any other imponant details)
c.We agree that Petitioner B‘s parenting time should be reserved because:
18. Public Assistance
If either party is receiving pubiic assistance from the State of Minnesota or applies for it
after this proceeding is started, notice of this marriage dissolution action must be given to
the county's collections and support office. See Minn. Stat. § 5 18A.44.
a.Petitioner A receives public assistance fiom the State of Minnesota: O YES © NO
1f YES, the assistance isfrom County. (Check all thatapply):
C3 MFIP in the amount of per month
D Tribal TANF in the amount of per month
DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 10 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
L} General Assistance in the amount of per month
D Medical Assistance
D Child Care Assistance E MinnesotaCare
b. Petitioner B receives public assistance fiom the State of Minnesota: O YES © NO
If YES, the assistance isfiom County. (Che ck all thatapply):
(:I MFIP in the amount of per month
[:1 Tribal TANF in the amount of per month
D General Assistance in the amount of per month
C] Medical Assistance
U Child Care Assistance U MinnesotaCare
c. The joint children of the parties receive public assistance fi’om the State O YES ® NO
of Minnesota:
If YES, the assistance is from County. (Check all that
apply):
D MFI'P D Medical Assistance B Tribal TANF D MinnesotaCare
D IV-E Foster Care
l9. Supplemental Seourity Income (SSI)
Supplemental Security Income (SSI) is a Federal income supplement program. It isavailable
to low-income people if they are over age 65, or blind or disabled.
a. Petitioner A receives Supplemental Security Income (SSI): O YES © NO
1F YES, in the amount of per month.
b. Petitioner B receives Supplemental Security Income (SSI): O YES © NO
IF YES, in the amount of per month.
c.The joint chiidren 0f the parties receive(s) Supplementai Security O YES © NO
Income (SSI):
IF YES, in the amount of per month
What is the name of the child receiving SSI?
20. Petitioner A's Employment
a.Petitioner A is empioyed: © YES O N0
b. Petitioner A is seIf-employed: O YES © N0
c. Petitioner A works at least 40 hours per week: © YES O NO
DIV1 702 State ENG Rev 5/1 9 www.mncourts.govfforms Page 11 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
'If'PetitionerA is unemployed or working less than 40 hours a week, answer these questions:
i.Why is Petitioner A unemployed or working Icss than 4O hours a week?
ii.What is Petitioner A‘s past work experience (types ofjobs, hours, pay, length of time at
the job, etc.) and what are Petitioner A's professional qualifications or iicenscs?
d. Current Employment: (1f Petitioner A has more than two jobs at this time, use an
attachment for the additional jobs.)
Park Nicollet/Methodist Hospital
Name of Petitioner A's Employer (If self-employed, listname and business address)
6500 Excelsior Blvd
Employer's Street Address
St. Louis Park MN 55426
City State Zip Code
Name of Petitioner A's Employer (If self~employed, listname and business address)
Employer's Street Address
City State Zip Code
DIV1 702 State ENG Rev 5/19 www.mncourts.govlfoms Page 12 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
Questions about Current
lst Job 2nd Job
Jobs
1's
Petitioner A paid by the
hour or salaried?
© hourly O salary O hourly O salary
What is the average number
of hours the Petitioner A 32-40 hours 0 hours
works per week?
How much overtime pay
does Petitioner A receive per $0 $0
week on average?
Does Petitioner A receive Iers, how much was If Yes, how much was
bonuses? received in bonuses last year? received in bonuses last year?
© Yes O No lst Job $ 300 $0
O Yes O No 2nd Job How much does Petitioner A How much does Petitioner A
expect to receive this year? expect to receive this year?
$ 1,000 $0
21. Petitioner A's Income
Source of Income Amount Per Month (or zero) before deductions/taxes
Self Empioyment Income $0.00 per month.
Self Employment income means gross receipts minus costs of goods sold, minus ordinary and
necessary business expenses.
Job with Park Nicollet/Methodist Hospital $6,670.00 per month.
Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)
Second job with per month.
Third job with per month.
Commissions from alljobs $0.00 per month.
Divide the total amount you expect this year by 12 to get a monthly average.
Unemployment benefits $0.00 per month.
Somal Secunty Renmmcnt, Survwors or Dlsabxhty
per month
Income (RSDI) (do not include SSI) $0 00
Investment and Rental Income $0.00 per month.
Annuity Payments $0.00 per month.
Pension or Disability from work or military $0.00 per month.
DIV1 702 State ENG Rev 5/1 Q www.mncourtsgov/forms Page 13 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
Worker's Compensation $0.00 per month.
Court—ordcred spousal maintenance you receive $0.00 per month.
Other income 0_ $0.00 per month.
Add all of the above: Total monthly income $6670.00 per month.
Enter the amount of child support Petitioner A is court- ,
ordered to pay for any non-j oint children $0.00 per month ‘
Enter the amount of spousal maintenance Petitioner A is
per month.
court-ordered to pay to your current or former spouse $0.00
Enter the amount of Social Security or Veteran's Benefits
received by a joint child because of Petitioner A's per month.
retirement, disability or other eligibility $0.00
Which parent receives the payment for the child? O Petitioner A O Petitioner B
22. Living Expenses for the Family
D a. Petitioner A and Petitioner B and their children are stillliving together.
Current monthly living expenses for the famin total
OR
b. Petitioner A and Petitioner B are living separately.
The monthly family living expenses before separation totaled $4,800.00
At this time, Petitioner A's separate monthly living expenses total $4,500.00
and Petitioner B’s monthly living expenses total $2,000.00
Of the totalcurrent monthly living expenses for Petitioner A, $2,500.00 isfor
expenses just for the children that live with Petitioner A. Of the total currentmonthly
livingexpenses for the Petitioner B, $200.00 is forexpenses just for the
children that live With the Petitioner B.
23. Expenses for Special Needs for the Children
a. lsthere a joint child of the parties who has special needs and Q YES © NO
extraordinary medicai expenses?
If Yes, Name of child with special needs
Describe the needs
D|V1702 State ENG Rev 5/19 www.mncourts.govlforms Page 14 of 49
27-FA-19-4415
Filed in District Court
State of Minnesota
8/2/2019 8:53 AM
b.Does Petitioner A‘s monthly living expense (stated at#22) include the O YES © N0
special needs expenses for the child?
c.Does Petitioner B’s monthly living expense (stated at#22) include the special Q YES © N0
needs expenses for the child?
24. Petitioner B's Employment
a. IsPetitioner B employed? ® YES O N0
b. Is Petitioner B self—employed? O YES ® N0
c. IsPetitioner B working at least 40 hours per week? O YES O N0
If Petitioner B is unemployed or working less than 40 hours a week, answer these questions:
i.Why is Petitioner B unemployed or working less than 40 hours a week?
ii.What is Petitioner B's past work experience (types ofjobs, hours, pay, length of time at
the job, etc.) and professional qualifications or licenses?
d.Current Employment: (If Petitioner B has more than two jobs at this time, use an
a
Preview
27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM magma. Coufig 533:3 w: {agilnnasaa State of Minnesota District Court County of: mac: m - .3 Bdiéiamgmcc Em WM Court File Number: &7‘ E A ‘ )q‘uq ‘ 5 Hmw t(fl Case Type: Dissoiution with Children In Re the Marriage of: Meghann, Michelle, Lawrence Joint Petition, Agreement, and Name of Petitioner A (first, middle’ 1a“) Judgment and Decree for Marriage and Dissolution With Children Steven, Francis, Lawrence Name of Petitioner B (first, m (idle, last) 1.Information about Petitioner A: Full Name: Meghann Michelle Lawrence First Middle Last Address: 41 17 Meadowbrook Lane Street Address Apt. No. St. Louis Park Hennepin MN 55426 City County State Zip Code Date of Birth: 1 1/23/1 977 Petitioner A's former or other names 01'write "None“: Meghann Michelle Rezabek First Middle Last First Middle Last Petitioner A's social securiqy number is listedon Confidential Form 11.1 and submitted along with the Joint Petition. 2.Information about Petitioner B: Full Name: Steven Francis Lawrence First Middle Last Address: 5400 West 70th Street 308 Street Address Apt. No. DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 1 0f49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM Edina Hennepin MN 55439 City County State Zip Code Date of Birth: 08/1 8/1 979 M". Petitioner B's former or other names or write "None . NONE First Middle Last First Middle Last Petitioner B's social security number is Iisted on Confidential Form and submitted aiong I 1.}, with the Joint Petition. 3. Our Marriage Petitioners were married on (month, day, year) 03, 7,2008 in the City of Grand Forks ,County of Grand Forks , State of North Dakota ,Country of USA 4. 180 Day Requirement a. Petitioner A has been living in Minnesota for the past six (6) months: © YES O NO b. Petitioner B has been living in Minnesota for the past six (6) months: ® YES O NO c. Petitioners were married in Minnesota, but neither Petitioner A nor O YES © NO Petitioner B reside in Minnesota, nor reside in ajurisdiction that will maintain an action for dissolution because of the sex or sexual orientation of the Petitioners. 5. Armed Forces a. Petitioner A is an active duty member of the armed forces: O YES © NO IF YES, has the member of the armed forces been stationed inMinnesota for the past six (6) months? O YES O NO b. Petitioner B is an active duty member of the armed forces: O YES © NO IF YES, has the member of the armed forces been stationed inMinnesota months? for the past six (6) O YES O NO 6. Marriage Cannot be Saved There has been an irren‘ievable breakdown of our marriage relationship. 7. Physical Living Situation Do the Petitioner A and Petitioner B live together at this time? O YES ® NO If NO, the date we separated was: 11/02/201 8 0N1 702 State ENG Rev 5/19 www.mncourtsgovlfon'ns Page 2 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM If YES, Petitioner A and Petitioner B are living together at this time because: 8. Other Proceedings a.Has a separate court case for marriage dissolution, legal separation, O YES © NO custody, paternity or annulment already been started by Petitioner A or Petitioner B in Minnesota or elsewhere? If YES, the type of court case is and itwas started in County, in the State of , and the court file number is and the status or outcome of the case is: O Open O Closed O Unknown 01' b.Has a County started a Support case involving the Petitioner A and O YES © N0 the Petitioner B or their chiidren? If YES, the case was started in County, in the State of and the- court file number is h The case D has been Dismissed fl isPending Q resulted with an Order for Support. 9. Protection or Harassment Order a.An Orderfor Protection or a Harassment/Restraining Order in O YES © NO efiect regarding Petitioner A and Petitioner B: If YES, the Order protects: D Petitioner A [j Petitioner B [:1 the children The Order was filed in County, on the date; , and the court file number is .A copy of the Order is submitted with this Joint Petition. b. If an Orderfor Protection isin effect, docs the Orderfbr O YES O NO Protection include a child support obligation? 10. Child Protection Case a.Has a child protection case invoiving Petitioner A and Petitioner B's O YES © NO children taken place in Minnesota or another state? If YES, the case is in County, DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 3 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM in the State 0f and the court file number is The name of the child or chiidren involved in the child protection case is: 11. Children Petitioner A and Petitioner B have Together (Joint Children) "Child" means a living person under the age 18, or under age 20 and stillin high school. a.List all joint children born before the marriage or born or adopted during the marriage. If there are no joint children, or if a spouse is not currently pregnant, yon are using the wrong form. Use Joint Petition, Agreement and Judgment and Decree Without Children. Fun Name or Child ”gig Age Chad Currently Lives With O Petitioner A O Petitioner B @ Both parents StellaJune Lawrence 01/1 2/201 O 9 OR (write in name) O Petitioner A O Petitioner B G 'eyson E ”gene © Both parents Lawrence 12/02/201 3 5 0R (wn'te in name) O Petitioner A O Petitioner B O Both parents OR (write in name) O Petitioner A O Petitioner B O Both parents OR (write in name) O Petitioner A O Petitioner B O Both parents OR (write in name) DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 4 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM The social security number of the children are listed on Confidential Form 11.1 and submitted along with the Joint Petition. If a child is Iiving with someone other than a parent, write the child's address below: Address : Street Address Apt. No‘ City County State Zip Code b. Has each child born to or adopted by Petitioner A and Petitioner B © YES O NO together lived in Minnesota for the past six (6) months? If NO, name the child or children, name the State(s) the child has lived in during the past 6 months, and the dates the chiid lived in each state: 12. Adult Dependent Children: Child support may be ordered for a joint child over the age of 18 who cannot support him/herself because of a physical or mental condition. a. Isthere an adult joint child born to or adopted by Petitioner A and O YES <9 N0 Petitioner B who is not able to support himfhcrself because of a physical or mental condition? If YES, the fun name, daze of birth and age of each adult dependent is: Full Name of Dependent Date of Birth Age The social scourity number of the adult dependent children are listed on Confidential Form 11.1 and submitted along with the Petition. l3. Pregnancy a. IsPetitioner A pregnant? O YES © NO If Petitioner A is pregnant, answer (i) and (ii): (i)The date the baby is due is (ii)Do Petitioner B and Petitioner A agree that Petitioner B is the O YES O NO biological father of the unborn child? IfNO, D Petitioner B D Petitioner A claims Petitioner B is not the biological father of the child. DIV1 702 State ENG Rev 5/19 wmmmncourtsgovlfonns Page 5 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM b. Is Petitioner B pregnant? O YES © NO 14. Petitioner A's Children from Other Relationship (Non-joint Children) a.Does Petitioner A have minor children born prior to the marriage O YES © NO fi'om another marriage or relationship? b. Has Petitioner A given binh during the marriage to a minor child OYES © NO who isnot a chiid of Petitioner B? If YES, answer and (iv): (i), (ii), (iii) (i).List the full name, dase of birth and age of each child born to Petitioner A since marrying Petitioner B, who is not a child of Petitioner B: ls Pemmne' A CW?“ Fun Name or Child and Date of Does Child Live with ordered to pay Child A ge Birth Petitioner A"' Support for this Child? OYES 0N0 oYEs 0N0 oYEs ONO oYEs 0N0 oYEs 0N0 oYEs 0N0 oYEs 0N0 oYEs 0N0 QYES 0N0 oYEs 0N0 (ii) Isthere a Court Order naming someone other than O YES O N0 Petitioner B as the father of the children listed in (i) above? If YES, attach a copy of the Order. The Order is for: Full Name of children (iii)Have Petitioner A and biological father signed a O YES O N0 Minnesota Recognition of Parentage (ROP) for any of the children fisted in (i) above? If YES, state the name of the child: Full Name of Children and attach a copy of the Recognition of Parentagc. If NO, why not? (iv) Has Petitioner B signed the "Spouse's NOn— O YES O NO Parentage Statement" for any of the. children listed at (i)above? DIV‘! 702 State ENG Rev 5/1 9 wmvmncourtsgov/forms Page 6 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM If YES, state the name of the child: and submit a copy of the "Spouse's Non-Parentage Statement." If NO, why not? 15. Petitioner B's Children from Other Relationship (Non—joint Children) a. Does Petitioner B have minor children born prior to the marriage from O YES ® NO another marriage or relationship? If YES, the full name, date of birth and age of each child born prior to the marriage is: Is Pet‘mne' B CWT" Fun Name of Child and Date of Does Child Live with ordered to pay Chad Age Birth Petitioner B"° Support for this Child? O YES O NO O YES O N0 OYES ONO OYES ONO OYES ONO OYES ONO OYES ONO OYES ONO OYES ONO OYES ONO b. Has Petitioner B given birth during the marriage to a minor child who is O YES © N0 not a child of Petitioner A? If YES, answer and (i), (ii), (iii) (iv): (i).List the fun name, date of birth and age of each child born to Petitioner B since marrying Petitioner A, who is not a child of the Petitioner A: Fun Name of Child and Date of Does Child Live with Is Pam“ B CWT" ordered t” Pay Chad Age Birth Petitioner B?' Support for this Child? oYEs 0N0 OYES 0N0 oYBs ONO oYEs 0N0 o YES ONO OYES 0N0 QYEs 0N0 oYEs 0N0 OYES 0N0 QYES 0N0 (ii) Is there a Court Order naming someone other than Petitioner A O YES O N0 as the father of the children listed in (i) above? If YES, submit a copy of the Order. The Order is for: DIV1 702 State ENG Rev 5/19 www.mncourtsgovfforms Page 7 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM Fufl Name of children (iii)Have Petitioner B and biological father signed a Minnesota O YES O N0 Recognition of Parentage (ROP) for any of the children Iisted in (i)above? If YES, state the name of the child: Full Name of Children and attach a copy of the Recognition of Parentage. If NO, why not? (iv) Has Petitioner A signed the "Spouse's Non-Parentage O YES O N0 Statement" for any of the children listed at (i)above? If YES, state the name of the child: and submit a copy of the "Spouse's Non—Parentage Statement." If NO, why not? 16. Custody It isin the child’s best interests and we agree that legal custody be granted as follows: (check one) © Joint legal custody to both parents O Sole legai custody to O Petitioner A O Petitioner B It isin the child's best interests and we agree that physical custody be granted as follows: (check one) © Joint physical custody to both parents O Sole physical custody t0 O PetitioncrA O Petitioner B 17. Parenting Time Petitioner A's parenting time with the joint children should be: (check one) If parenting time is unsupervised for both parents, skip to Question 18. © unsupervised O supervised O reserved For supervised parenting time answer a and b. For reserved parenting time, answer c. DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 8 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM (Option 1) Supervision isnecessary because unsupervised parenting time islikely to endanger the child's physical or emotional health or impair the child's emotional development. The circumstances supporting this finding are: (Option 2) We agree that supervised parenting time is necessary because It isin the best interests of the children that Petitioner A's parenting time be supervised as follows: (State who should supervise the parenting time, and if there isa cost involved, who should pay the cost and any other important details) c.We agree that Petitioner A‘s parenting time should be reserved because: Petitioner B's parenting time with the joint children should be: (check one) © unsupervised O supervised O reserved For supervised parenting time answer a and b. For reserved parenting time, answer c. DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 9 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM (Option .1) Supervision isnecessary because unsupervised parenting time islikely to endanger the chiid‘s physical or emotional health or impair the child's emotional development. The circumstances supporting this finding are: (Option 2) We agree that supervised patenting time is necessaly because b. It is in the best interestsof the children that Petitioner B's parenting time be supervised as follows: (State who should supervise the parenting time, and if there is a cost involved, who should pay the cost and any other imponant details) c.We agree that Petitioner B‘s parenting time should be reserved because: 18. Public Assistance If either party is receiving pubiic assistance from the State of Minnesota or applies for it after this proceeding is started, notice of this marriage dissolution action must be given to the county's collections and support office. See Minn. Stat. § 5 18A.44. a.Petitioner A receives public assistance fiom the State of Minnesota: O YES © NO 1f YES, the assistance isfrom County. (Check all thatapply): C3 MFIP in the amount of per month D Tribal TANF in the amount of per month DIV1 702 State ENG Rev 5/19 www.mncourts.govlforms Page 10 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM L} General Assistance in the amount of per month D Medical Assistance D Child Care Assistance E MinnesotaCare b. Petitioner B receives public assistance fiom the State of Minnesota: O YES © NO If YES, the assistance isfiom County. (Che ck all thatapply): (:I MFIP in the amount of per month [:1 Tribal TANF in the amount of per month D General Assistance in the amount of per month C] Medical Assistance U Child Care Assistance U MinnesotaCare c. The joint children of the parties receive public assistance fi’om the State O YES ® NO of Minnesota: If YES, the assistance is from County. (Check all that apply): D MFI'P D Medical Assistance B Tribal TANF D MinnesotaCare D IV-E Foster Care l9. Supplemental Seourity Income (SSI) Supplemental Security Income (SSI) is a Federal income supplement program. It isavailable to low-income people if they are over age 65, or blind or disabled. a. Petitioner A receives Supplemental Security Income (SSI): O YES © NO 1F YES, in the amount of per month. b. Petitioner B receives Supplemental Security Income (SSI): O YES © NO IF YES, in the amount of per month. c.The joint chiidren 0f the parties receive(s) Supplementai Security O YES © NO Income (SSI): IF YES, in the amount of per month What is the name of the child receiving SSI? 20. Petitioner A's Employment a.Petitioner A is empioyed: © YES O N0 b. Petitioner A is seIf-employed: O YES © N0 c. Petitioner A works at least 40 hours per week: © YES O NO DIV1 702 State ENG Rev 5/1 9 www.mncourts.govfforms Page 11 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM 'If'PetitionerA is unemployed or working less than 40 hours a week, answer these questions: i.Why is Petitioner A unemployed or working Icss than 4O hours a week? ii.What is Petitioner A‘s past work experience (types ofjobs, hours, pay, length of time at the job, etc.) and what are Petitioner A's professional qualifications or iicenscs? d. Current Employment: (1f Petitioner A has more than two jobs at this time, use an attachment for the additional jobs.) Park Nicollet/Methodist Hospital Name of Petitioner A's Employer (If self-employed, listname and business address) 6500 Excelsior Blvd Employer's Street Address St. Louis Park MN 55426 City State Zip Code Name of Petitioner A's Employer (If self~employed, listname and business address) Employer's Street Address City State Zip Code DIV1 702 State ENG Rev 5/19 www.mncourts.govlfoms Page 12 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM Questions about Current lst Job 2nd Job Jobs 1's Petitioner A paid by the hour or salaried? © hourly O salary O hourly O salary What is the average number of hours the Petitioner A 32-40 hours 0 hours works per week? How much overtime pay does Petitioner A receive per $0 $0 week on average? Does Petitioner A receive Iers, how much was If Yes, how much was bonuses? received in bonuses last year? received in bonuses last year? © Yes O No lst Job $ 300 $0 O Yes O No 2nd Job How much does Petitioner A How much does Petitioner A expect to receive this year? expect to receive this year? $ 1,000 $0 21. Petitioner A's Income Source of Income Amount Per Month (or zero) before deductions/taxes Self Empioyment Income $0.00 per month. Self Employment income means gross receipts minus costs of goods sold, minus ordinary and necessary business expenses. Job with Park Nicollet/Methodist Hospital $6,670.00 per month. Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month) Second job with per month. Third job with per month. Commissions from alljobs $0.00 per month. Divide the total amount you expect this year by 12 to get a monthly average. Unemployment benefits $0.00 per month. Somal Secunty Renmmcnt, Survwors or Dlsabxhty per month Income (RSDI) (do not include SSI) $0 00 Investment and Rental Income $0.00 per month. Annuity Payments $0.00 per month. Pension or Disability from work or military $0.00 per month. DIV1 702 State ENG Rev 5/1 Q www.mncourtsgov/forms Page 13 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM Worker's Compensation $0.00 per month. Court—ordcred spousal maintenance you receive $0.00 per month. Other income 0_ $0.00 per month. Add all of the above: Total monthly income $6670.00 per month. Enter the amount of child support Petitioner A is court- , ordered to pay for any non-j oint children $0.00 per month ‘ Enter the amount of spousal maintenance Petitioner A is per month. court-ordered to pay to your current or former spouse $0.00 Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Petitioner A's per month. retirement, disability or other eligibility $0.00 Which parent receives the payment for the child? O Petitioner A O Petitioner B 22. Living Expenses for the Family D a. Petitioner A and Petitioner B and their children are stillliving together. Current monthly living expenses for the famin total OR b. Petitioner A and Petitioner B are living separately. The monthly family living expenses before separation totaled $4,800.00 At this time, Petitioner A's separate monthly living expenses total $4,500.00 and Petitioner B’s monthly living expenses total $2,000.00 Of the totalcurrent monthly living expenses for Petitioner A, $2,500.00 isfor expenses just for the children that live with Petitioner A. Of the total currentmonthly livingexpenses for the Petitioner B, $200.00 is forexpenses just for the children that live With the Petitioner B. 23. Expenses for Special Needs for the Children a. lsthere a joint child of the parties who has special needs and Q YES © NO extraordinary medicai expenses? If Yes, Name of child with special needs Describe the needs D|V1702 State ENG Rev 5/19 www.mncourts.govlforms Page 14 of 49 27-FA-19-4415 Filed in District Court State of Minnesota 8/2/2019 8:53 AM b.Does Petitioner A‘s monthly living expense (stated at#22) include the O YES © N0 special needs expenses for the child? c.Does Petitioner B’s monthly living expense (stated at#22) include the special Q YES © N0 needs expenses for the child? 24. Petitioner B's Employment a. IsPetitioner B employed? ® YES O N0 b. Is Petitioner B self—employed? O YES ® N0 c. IsPetitioner B working at least 40 hours per week? O YES O N0 If Petitioner B is unemployed or working less than 40 hours a week, answer these questions: i.Why is Petitioner B unemployed or working less than 40 hours a week? ii.What is Petitioner B's past work experience (types ofjobs, hours, pay, length of time at the job, etc.) and professional qualifications or licenses? d.Current Employment: (If Petitioner B has more than two jobs at this time, use an a