Preview
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Filed in District Court
State of Minnesota
JAN 2 0 2023
State of Minnesota District Court
County of: Judicial District: 4th
Hennepin Court File Number: {7'PA' ..
Case Type: Dissolution with Children
In Re the Marriage of:
war.)
Name of P 'itionerA (First, Middle, Last)
Joint Petition, Agreement, and
and Judgment and Decree for
Marriage Dissolution
With Children
Km me HtlQQi CM limit/1 C3
Name of PetitionerB(First, Middle, Last)
1. Information about Petitioner A:
Full Name: 12*)" DELHQ'QDCMN'W lNVKUWLQ
SVminve
First ,/ Middle Last
Address: l "M Mme,New
Street Address
swim/w.J toe
Apt. No.
Wm (MM/i Comm Her/m eigm HM
State
ERMISG
Clty County Zip Code
Date of Birth: 0'3» C961 "(6176'
Month Day Year
Petitioner A's former or other names: (WYAJA {MC/pm
(Or write' none) \Stl/UJ/W Middle Last
First Middle Last
Petitioner A's social security number is listed on Confidential Form 111 and submitted
along with the Joint Petition.
2. Information about Petitioner B:
Full Name: "ULU First
l (U HClSgW/l/l
Middle
MKS V" ('7
Last
Addressz \lC) U 11M (\\ /@
Strebt Address Apt. No.
. .
,
lM \ \m lemmri\
n Q Hmw<flhn NW
State
7:75 U//[/
City County Zip Code
DIV1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 1 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Date of Birth: C L/ C7 C1 i (l (3/3
Month Day Year
Petitioner B's former or other names: MOW,
(Or write "none") First Middle Last
First Middle Last
Petitioner B's social security number is listed on Confidential Form 11.1 and submitted
along with the Joint Petition.
0" ' (DR-M
3. Our Marriage
Petitioners were married on: (month,day,year)
in the City of "ofibfli\\\{x State
of H1\V\V\€.$U:\IC\
County
of (\YVWUA
orMQ'ga.'
Country
, ,
,
Q'VCQYtTg
4. 180 Day Requirement
a. Petitioner A has been living in Minnesota for the past six (6) months: [E YES [:1 NO
b. Petitioner Bhas been living in Minnesota for the past six (6) months: Ea YES El NO
c. Petitioners were married in Minnesota, but neither Petitioner A nor Petitioner B reside 3
in Minnesota, nor reside in a jurisdiction that will maintain an action for dissolution
because of the sex or sexual orientation of the Petitioners. I] YES E NO
5. Armed Forces
a. Petitioner A is an active duty member of the armed forces: I] YES E NO
If YES, has the member of the armed forces been stationed in Minnesota for the past six
(6) months? D YES D NO
b. Petitioner B is an active duty member of the armed forces: I] YES NO
If YES, has the member of the armed forces been stationed in Minnesota for the past six
(6) months? [:1 YES I] NO
6. Marriage Cannot be Saved
There has been an irretrievable breakdown of our marriage relationship.
DIV1702 State ENG Rev 5/19 www.mncourts.gov/fornts 2 of 50
Page
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
7. Physical Living Situation
Do Petitioner A and Petitioner Blive together at this time?D YES NO
J gm AOA\
If NO, the date of separation wasQCLVii MENU
Month Day Year
If YES, Petitioner A and Petitioner B are living together at this time because:
8. Other Proceedings
a. Has aseparate court case for marriage dissolution, legal separation, annulment, custody,
parenting time, or paternity has already been started by Petitioner A or Petitioner B in
Minnesota or another state: D YES NO. If YES, the type of court case is:___
and it was started in County in the State of
and the Court file number is , and the outcome of
the case is:
U Open D Closed D Unknown or U
b. Has a County started a aipport case involving PetitionerA and PetitionerB or their
children? D YES NO. If YES, the case was started in
County in the State of and court file number is
The case D has been Dismissed D is Pending D resulted with an Order for Support.
9. Protection or Harassment Order
a. An Order for Protection or a Harassment/Restraining Order is in effect regarding
Petitioner A and Petitioner B: D YES m NO. If YES, the Order protects:
D Petitioner A U Petitioner B D the children. The Order was filedin
County on the date: , and the Court file
number is . A copy of the Order is submitted along with this
Joint Petition.
b. If an Order for Protection is in effect, does the Order for Protection include a child
support obligation? El YES D NO
DN1702 State BIG Rev 5/19 www.mcourtsgovlforms Page 3 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
10. Child Protection Case
Has a Child Protectiml case involving Petitioner A and Petitioner B's Children taken place
in Minnesota or another state. D YES m NO
If YES, the case is in County in the State of
and the Court file number is . The name of the child or
children involved in the Child Protection case is:
11. Children Petitioner A and Petitioner B have Together (Joint Children)
"Child" means a living person under age 18, or under age 20 and still in 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, you are using the
wrong form. Use JointPetition, Agreementand Judgmentand Decree WithoutChiIdren.
Full Name of Child Date of Age Child Currently Lives With
Birth
El Petitioner A DPetitioner B
-~(\W;e,\( "Cm: cm 10103] 1"" 3W: .Both parents
OR
Mmamo
(write in name)
Elpemioner A Elpetitioner B
D Both parents
OR
(write in name)
DPetitioner A UPetitioner B
E] Both parents
OR
(write in name)
DPetitioner A DPetitioner B
DBoth parents
OR
(write in name)
DPetitioner A EIPetitioner B
E] Both parents
OR
(write in name)
DlV 1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 4 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
The social security number of the children is/are listed on Confidential Form 11.1 and
submitted along with the Joint Petition.
If a child is living 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 together lived in
Minnesota for the past six (6) months?
W YES D NO
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 child lived in each state:
12. Adult De pende nt Childre n : Child suppott may be ordered fora joint child overthe age of 18 who
cannot support him/herself because of a physical or mental condition.
Is there an adult joint child born to or adopted by Petitioner A and Petitioner B who is not
able to support himself or herself because of a physical or mental condition?
D YES m No
If YES, the full name, date of birth and age of each adult dependent is:
Full Name of Dependent Date of Birth Age
The social security number of the adult dependent children are listed on Confidential Forrn 11.1
and submitted along with the Joint Petition.
13. Pregnancy
a. IsPetitionerApregnant? D YES NoE
If Petitioner A is pregnant answer (i) and (ii):
DtV1702 State BIG Rev 5/19 ww.mncourts.govlforms Page 5 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
i. The date the baby is due is
Month Day Year
ii. Do Petitioner B and Petitioner A agree that Petitioner B is the biological father of
the unborn child? D YES D NO
If N O, D Petitioner B D Petitioner A claims Petitioner B is not the biological father
of the child.
b. Is Petitioner B pregnant? D YES NO
If Petitioner B is pregnant answer (i) and (ii):
i. The date the baby is due is
Month Day Year
ii. Do Petitioner B and Petitioner A agree that Petitioner A is the biological father of
the unborn child? D YES D NO
If NO, D PetitionerB D PetitionerA claims PetitionerAis not the biological father
of the child.
14. Petitioner A's Children from Other Relationship (Non-joint Children)
a. Does PetitionerA have minor children born prior to themarriage frorn another marriage
or relationship? D YES Q NO
If YES, the full name, date of birth and age of each child born prior to the marriage is:
Full Name of Date of Does ChildLive Is Petitioner A Court-Ordered
Child and Age Birth with Petitioner to pay Child Support for this
A? Child?
l:| YES [:1 NO El YES El NO
L_l YES l_l NO L_J YES l_] NO
[:1 YES 1:] NO [:1 YES D NO
L] YES LJ NO LJ YES L] NO
b. Has Petitioner A given birth during the marriage to a minor child who is not a child of
Petitioner B? D YES m No
If YES, answer (i) , (ii), (iii) and ( iv):
i. List the full name, date of birth and age of each child born to PetitionerA since
marrying Petitioner B, who is not a child of the Petitioner B:
DIV1702 State BIG Rev 5/19 www.mncourts.gov/forrns Page 6 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Full Name ofChiId and Date (if Does Child Is Petitioner A Coun-
Age Birth Live with Ordered to pay Child
Petitioner A? Support for this Child?
DYESDNQ DYES D NO
UYESLINO LJYES I_l NO
ii. Is there a Court Order naming someone other thaJl the Petitioner B as the father of
the children listed in (i) above? [j YES D No
If YES, submit a copy of the Order. The Order is for:
Full Name of Children
iii. Have the Petitioner A and biological Father signed a Minnesota Recognition of
Parentage (ROP) for any of the children listed in (i) above? D YES D NO
If YES, state the full name of the child: and
attach a copy 0f the Recognition of Parentage.
If N0, why not?
iv. Has Petitioner B signed the "Spouse's Non-Parentage Statement" for any of the
Children listed at (i) above? D YES D NO
If YES, state the name of the child:
and submit a copy of the "Spouse's Non-Pare ntage State men ."
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 another
marriage or relationship? D YES m NO
If YES, the full name, date of birth and age of each child born prior to the marriage is:
Full Name of Child and Date of Does Child Live Is Petitioner B Court-
Age Birth with Pe titio ne r Ordered to pay Child
B? Suppon for this
C hild?
LJ YES LI NO l_l YES Ll NO
El YES E] NO [I YES [:1 NO
L_l YES LJ NO Ll YES LI NO
E] YES E] NO 1:] YES {:1 NO
DtV1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 7 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
b. Has Petitioner B given birth during the marriage to a minor Child who is not a Child
of Petitioner A? D YES E NO
If YES, answer (i) , (ii), (iii) and ( iv):
i. List the full 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:
Full Name of Child and Date of Does Child Is Petitioner B Court-
Age B irth Live with Ordered to pay Child
Petitioner B? Support for this Child?
L__l YES |_l NO Ll YES |_l NO
D YES D No D YES El No
ii. Is there a Court Order naming someone otherthan the Petitioner A as the father
of the children listed in (i) above? D YES D NO
If YES, submit a copy of the Order. The Order is for:
Full Name of Children
iii. Have Petitioner B and biological Father signed a Minnesota Recognition of
Parentage (ROP) for any of the children listedin (i) above? D YES D NO
If YES, state the full name of the child: and
attach a copy of the Recognition of Parentage.
If NO, why not?
iv. Has the Petitioner A signed the "Spouse's Non-Parentage Statement " for any
of the children listed at (i) above? D YES D NO
If YES, state the name of the child:
and submit a copy of the "Spouse's NonPare ntage Statement."
If NO, why not?
16. Custody
It is in the child's best interests and we agree that legal custody be granted as follows:
(check one)
m Joint legal custody to both parents
D Sole legal custody to D PetitionerA D Petitioner B
DIV1702 State ENG Rev 5/19 www.mncourtsgov/forns Page 8 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
It is in the child's best interests and we agree that physical custody be granted as follows:
(check one)
$ Joint physical custody to both parents
D Sole physical custody to D PetitionerA D Petitioner B
17. Parenting Time
a. It is in the best interests of the children that:
Petitioner A's parenting time with the joint children be: (check one)
unsupervised D supervised D reserved
Petitioner B's parenting time with the joint children be: (check one)
E; unsupervised U supervised D reserved
If parenting time is unsupervised for both parents, skip to Question 18.
b. supervised parenting time
(Option 1) Supervision is necessary because unsupervised parenting time is likely 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 is in the best interests of the children that supervision of parenting time be arranged as
follow: (State who should supervise parenting time, and if there is a cost involved, who
should pay the cost, and any other important details)
DN 1702 State BIG Rev 5/19 www.mncourtsgov/forms Page 9 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
C. Reserved Parenting time
We agree that parenting time should be reserved because:
18. Public Assistance (Note: If either pers on is receiving public assistance fromthe State of Minnesotaor
:
applies forit after this proceeding is started, notice of this marriage dissolution action mustbe given to Publ'r
Authority office. See Minn. Stat. § 518A.44)
a. Petitioner A receives public assistance from the State of Minnesota: E Yes D No
If YES, the assistance is from Hennepln
County. (checkallthat apply)
D MFIP in the amount of $ Qi Q6 er month
D Tribal TANF in the amount of $ 0 sag "per month
D General Assistance in the amount of $ Q' QQ per month
fl Medical Assistance
D Child Care Assistance D MinnesotaCare
b. Petitioner B receives public assistance from the State of Minnesota: D Yes No
If YES, the assistance is from County. (checkallthat apply)
D MFIP in the amount of $ per month
U Tribal TANF in the amount of $ per month
D General Assistance in the amount of $ per month
D Medical Assistance
D Child Care Assistance D MinnesotaCare
c. The joint children of the parties receive public assistance from the State of Minnesota:
D Yes No
If YES, the assistance is from County. (Check all that apply):
D MFIP D Medical Assistance D Tribal TANF D MinnesotaCare
D IVE Foster Care
19. Supple me ntal Se curity Income (SSI)
Supplemental Security Income (SSI) is a Federal income supplement program It is available to low-
income people if they are over age 65, or blind, or disabled.
DIV1702 State ExiG Rev 5/19 www.rnncourts.gov/forms Page 10 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
a. Petitioner A receives Supplemental Security Income (SSI): M' N0 D Yes in the
amount of $ per month.
b. PetitionerB receives Supplemental Security Income (SSI): No D Yes in the
amount of $ per month.
c. The joint children of the parties 1'eceive(s) Supplemental Security Income (SSI):
N0 D Yes in the amount 0f$
$ per month. What isthe name
of the child receiving SSI?
20. Petitioner A's Employment
a. Petitioner A is employed: m Yes D No
b. Petitioner A is selfemployed: D Yes E No
c. Petitioner A works at least 40 hours per week: E Yes D No
If Petitioner A is unemployed or working less than 4O hours / week, answer these
questions:
i. Why is Petitioner A unemployed or working less than 4O hours / week?
ii. What is Petitioner A's past work experience (type of jobs, hours, pay, length of time
at the job) and what are Petitioner A's professional qualifications or licenses?
d. Current Employlnent: (if PetitionerA currently has more than two jobs, use an attachment forthe
additional jobs.)
who
Name of Petitioner A's Employer (If self-employed, list name and business address)
"CM 'Muuk
Employer's Street Address
M 3%
host mNL PM
State
355%?!
w
City Zip Code
Name of Petitioner A's Employer if self-employed, list name and business address)
DIV 1702 State ENG Rev 5/19 www.mncourts.gov/forrns Page 11 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Employer's Street Address
City State Zip Code
Questions about Current Jobs 1" Job 2"" Job
Is Petitioner A paid by the hour m hourly D salary D hourly D salary
or salaried?
What is the average number of
hours Petitioner A works per
<10 hours hours
week?
How much overtime pay does
Petitioner A receive per week on
average?
$0.00 $
Does Petitioner A rec eive If Yes, how much was received If Yes, how much was
in bonus es last year? received in bonuses last year?
bonuses?
$ $
DYes m No 15' Job How much does Petitioner A How much does Petitioner A
DYes D No 2nd Job expect to receive this year? expect to receive this year?
$ $
21. Petitioner A's Income
Source of Income Amount Per Month (or zero) before de ductions/taxes
Self Employment Income 55 '0 per month
Self Employment income means gross receipts minus costs of goods sold minus ordinary and necessary
M
business
expenses].
Job with
3031 $ 91003 per month
Monthly income froma job Ho rly wage xHours worked per week x433 (weeks per month)
Second Job with v $ 0
' 00
per month
Third Job with $ 0 O C; permonth
[3*
I
.
Commissions from all jobs $ C) t 0 per month
Divide the total armunt you expect this year by 12 to get a monthly average
Unemployment benefits $ I (30 per montli
Social Security Retirement, Survivors or Disability
Income (RSDI) (do not include 881) $ 0 t O 0 per month
Investment and Rental Income $ 0 t (l 6 per month
Annuity payments $QQ
. O 0 per month
D|V1702 State ENG Rev 5/19 www.mncourtsgov/forms Page 12 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Pension or Disability from work or military $ per montli
Worker's Compensation $ per month
Court-ordered spousal maintenance received $ per month
Other income $ per month
List Source
Add all of the above. Total monthly income $ Der month
Enter the amount of child support Petitioner A is court-ordered
to pay for any non-joint children $ per month
Enter the amount of spousal maintenance Petitioner A is court-ordered
to pay to a current or former spouse $ per month
Enter the amount of Social Security or Veteran's Benefits received by a joint child
because of Petitioner A's retirement, disability, or other eligibility
per month
Which parent receives the payment for the child?
D Petitioner A D Petitioner B
22. Living Expenses for the Family
D a. Petitioner A and Petitioner B and their children are still living together. Current
monthly living expenses for the family total $4,. _
OR
E b. PetitionerA and Petitioner B are living separately. The monthly family living
expenses before separation totaled $ OO . At this time, Petitioner A's separate
monthly living expenses total $ {/fig , and Petitioner B's monthly living expenms
total $ 900 . Of the total current monthly living expenses for PetitionerA,
$ 31'10 amount is for expenses just for the children that live(s) with Petitioner
A. Of the total current monthly living expenses for Petitioner B, $ -2 '20! '} is for
expenses just for the children that live(s) with Petitioner B.
23. Expenses for Special Needs for the Children
a. Is there a joint child of the parties who has special needs and extraordinary medical
expenses? D YES fl NO If Yes,
Name of child with special needs:
DN1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 13 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Describe the needs:
b.Does Petitioner A's monthly living expense (stated at #22) include the special needs
expenses for the child? D YES D NO
c. Does Petitioner B's monthly living expense (stated at #22) include the special needs
expenses for the child? D YES D NO
24. Petitioner B's Employment
a. Is Petitioner B employed? YES D NO
b. ls Petitioner Bselfemployed? D YES $ NO
c. Is Petitioner B working at least 40 hours per week? E YES D NO
If Petitioner B is unemployed or works less than 40 hours/week, answer these
questions:
i. Explain why Petitioner B is not workmg or why Petitioner B works less than 40
hours/week
ii. What is Petitioner B's past work experience (type of jobs, hours, pay, length of
time at the job) and professional qualifications or licenses?
d. Current Employment: (If PetitionerBhas more than two jobs at this time, use an attachment for the
additional jobs.)
0? WW
Néme'of Petitioner B's Empby'er (If Self-Employed list n me and business address)
\1o'\\ ohm 0mm
Employer's Street Address
EN Q
Wilde (wow MW
State
613%?
City Zip Code
DIV1702 State ENG Rev 5/19 www.mncourts.gov/forrns Page 14 of 50
27-FA-23-357
Filed in District Court
State of Minnesota
2/16/2023 10:44 AM
Name of Petitioner B's Employer (If Self-Employed list name and business address)
Employer's Street Address
City State Zip Code
Questions about Jobs 1" Job 2"" Job
Is Petitioner B paid by the hour or [fl] hourly LJ salary hourly LI salary
salaried?
What is the average number of hours hours
hours Petitioner B works per week?
é?"
How much overtime pay does
Petitioner B receive per week on
$ QsOQ $
average?
Does Petitioner B receive bonuses? If Yes, how much did If Yes, how much did
Petitioner B receive in bonuses Petitioner B receive in
DYes mNo 15'Job
last year? bonuses last year?
UYes mNo 2"dJob $ $
How much does Petitioner B How much does Petitioner B
expect to receive this year? expect to receive this year?
$ $
25. Petitioner B's Income
Source of Income Amount PerMonth (or zero) before de ductions/taxes
Self Employment Income $ Ell O O per month
Self Employment income means gross receipts minus costs of goods sold minus ordinary and necessary
business expenses.
Job with
E CW =
\I $ Q '0 OO per month
Monthly income froma job wage xI-Iours worked per week x433 (weeks per month)
Second Job with Hovrbly l
$ per month
Third Job with N (W $ O r 00 per month
Commissions from all jobs $ (D v O per month
Divide the total amount you expect this year by 12 to get a monthly average
Unemployment benefits $ C.) ' O per month
Social Security Retirement,
Preview
27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Filed in District Court State of Minnesota JAN 2 0 2023 State of Minnesota District Court County of: Judicial District: 4th Hennepin Court File Number: {7'PA' .. Case Type: Dissolution with Children In Re the Marriage of: war.) Name of P 'itionerA (First, Middle, Last) Joint Petition, Agreement, and and Judgment and Decree for Marriage Dissolution With Children Km me HtlQQi CM limit/1 C3 Name of PetitionerB(First, Middle, Last) 1. Information about Petitioner A: Full Name: 12*)" DELHQ'QDCMN'W lNVKUWLQ SVminve First ,/ Middle Last Address: l "M Mme,New Street Address swim/w.J toe Apt. No. Wm (MM/i Comm Her/m eigm HM State ERMISG Clty County Zip Code Date of Birth: 0'3» C961 "(6176' Month Day Year Petitioner A's former or other names: (WYAJA {MC/pm (Or write' none) \Stl/UJ/W Middle Last First Middle Last Petitioner A's social security number is listed on Confidential Form 111 and submitted along with the Joint Petition. 2. Information about Petitioner B: Full Name: "ULU First l (U HClSgW/l/l Middle MKS V" ('7 Last Addressz \lC) U 11M (\\ /@ Strebt Address Apt. No. . . , lM \ \m lemmri\ n Q Hmw<flhn NW State 7:75 U//[/ City County Zip Code DIV1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 1 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Date of Birth: C L/ C7 C1 i (l (3/3 Month Day Year Petitioner B's former or other names: MOW, (Or write "none") First Middle Last First Middle Last Petitioner B's social security number is listed on Confidential Form 11.1 and submitted along with the Joint Petition. 0" ' (DR-M 3. Our Marriage Petitioners were married on: (month,day,year) in the City of "ofibfli\\\{x State of H1\V\V\€.$U:\IC\ County of (\YVWUA orMQ'ga.' Country , , , Q'VCQYtTg 4. 180 Day Requirement a. Petitioner A has been living in Minnesota for the past six (6) months: [E YES [:1 NO b. Petitioner Bhas been living in Minnesota for the past six (6) months: Ea YES El NO c. Petitioners were married in Minnesota, but neither Petitioner A nor Petitioner B reside 3 in Minnesota, nor reside in a jurisdiction that will maintain an action for dissolution because of the sex or sexual orientation of the Petitioners. I] YES E NO 5. Armed Forces a. Petitioner A is an active duty member of the armed forces: I] YES E NO If YES, has the member of the armed forces been stationed in Minnesota for the past six (6) months? D YES D NO b. Petitioner B is an active duty member of the armed forces: I] YES NO If YES, has the member of the armed forces been stationed in Minnesota for the past six (6) months? [:1 YES I] NO 6. Marriage Cannot be Saved There has been an irretrievable breakdown of our marriage relationship. DIV1702 State ENG Rev 5/19 www.mncourts.gov/fornts 2 of 50 Page 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM 7. Physical Living Situation Do Petitioner A and Petitioner Blive together at this time?D YES NO J gm AOA\ If NO, the date of separation wasQCLVii MENU Month Day Year If YES, Petitioner A and Petitioner B are living together at this time because: 8. Other Proceedings a. Has aseparate court case for marriage dissolution, legal separation, annulment, custody, parenting time, or paternity has already been started by Petitioner A or Petitioner B in Minnesota or another state: D YES NO. If YES, the type of court case is:___ and it was started in County in the State of and the Court file number is , and the outcome of the case is: U Open D Closed D Unknown or U b. Has a County started a aipport case involving PetitionerA and PetitionerB or their children? D YES NO. If YES, the case was started in County in the State of and court file number is The case D has been Dismissed D is Pending D resulted with an Order for Support. 9. Protection or Harassment Order a. An Order for Protection or a Harassment/Restraining Order is in effect regarding Petitioner A and Petitioner B: D YES m NO. If YES, the Order protects: D Petitioner A U Petitioner B D the children. The Order was filedin County on the date: , and the Court file number is . A copy of the Order is submitted along with this Joint Petition. b. If an Order for Protection is in effect, does the Order for Protection include a child support obligation? El YES D NO DN1702 State BIG Rev 5/19 www.mcourtsgovlforms Page 3 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM 10. Child Protection Case Has a Child Protectiml case involving Petitioner A and Petitioner B's Children taken place in Minnesota or another state. D YES m NO If YES, the case is in County in the State of and the Court file number is . The name of the child or children involved in the Child Protection case is: 11. Children Petitioner A and Petitioner B have Together (Joint Children) "Child" means a living person under age 18, or under age 20 and still in 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, you are using the wrong form. Use JointPetition, Agreementand Judgmentand Decree WithoutChiIdren. Full Name of Child Date of Age Child Currently Lives With Birth El Petitioner A DPetitioner B -~(\W;e,\( "Cm: cm 10103] 1"" 3W: .Both parents OR Mmamo (write in name) Elpemioner A Elpetitioner B D Both parents OR (write in name) DPetitioner A UPetitioner B E] Both parents OR (write in name) DPetitioner A DPetitioner B DBoth parents OR (write in name) DPetitioner A EIPetitioner B E] Both parents OR (write in name) DlV 1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 4 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM The social security number of the children is/are listed on Confidential Form 11.1 and submitted along with the Joint Petition. If a child is living 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 together lived in Minnesota for the past six (6) months? W YES D NO 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 child lived in each state: 12. Adult De pende nt Childre n : Child suppott may be ordered fora joint child overthe age of 18 who cannot support him/herself because of a physical or mental condition. Is there an adult joint child born to or adopted by Petitioner A and Petitioner B who is not able to support himself or herself because of a physical or mental condition? D YES m No If YES, the full name, date of birth and age of each adult dependent is: Full Name of Dependent Date of Birth Age The social security number of the adult dependent children are listed on Confidential Forrn 11.1 and submitted along with the Joint Petition. 13. Pregnancy a. IsPetitionerApregnant? D YES NoE If Petitioner A is pregnant answer (i) and (ii): DtV1702 State BIG Rev 5/19 ww.mncourts.govlforms Page 5 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM i. The date the baby is due is Month Day Year ii. Do Petitioner B and Petitioner A agree that Petitioner B is the biological father of the unborn child? D YES D NO If N O, D Petitioner B D Petitioner A claims Petitioner B is not the biological father of the child. b. Is Petitioner B pregnant? D YES NO If Petitioner B is pregnant answer (i) and (ii): i. The date the baby is due is Month Day Year ii. Do Petitioner B and Petitioner A agree that Petitioner A is the biological father of the unborn child? D YES D NO If NO, D PetitionerB D PetitionerA claims PetitionerAis not the biological father of the child. 14. Petitioner A's Children from Other Relationship (Non-joint Children) a. Does PetitionerA have minor children born prior to themarriage frorn another marriage or relationship? D YES Q NO If YES, the full name, date of birth and age of each child born prior to the marriage is: Full Name of Date of Does ChildLive Is Petitioner A Court-Ordered Child and Age Birth with Petitioner to pay Child Support for this A? Child? l:| YES [:1 NO El YES El NO L_l YES l_l NO L_J YES l_] NO [:1 YES 1:] NO [:1 YES D NO L] YES LJ NO LJ YES L] NO b. Has Petitioner A given birth during the marriage to a minor child who is not a child of Petitioner B? D YES m No If YES, answer (i) , (ii), (iii) and ( iv): i. List the full name, date of birth and age of each child born to PetitionerA since marrying Petitioner B, who is not a child of the Petitioner B: DIV1702 State BIG Rev 5/19 www.mncourts.gov/forrns Page 6 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Full Name ofChiId and Date (if Does Child Is Petitioner A Coun- Age Birth Live with Ordered to pay Child Petitioner A? Support for this Child? DYESDNQ DYES D NO UYESLINO LJYES I_l NO ii. Is there a Court Order naming someone other thaJl the Petitioner B as the father of the children listed in (i) above? [j YES D No If YES, submit a copy of the Order. The Order is for: Full Name of Children iii. Have the Petitioner A and biological Father signed a Minnesota Recognition of Parentage (ROP) for any of the children listed in (i) above? D YES D NO If YES, state the full name of the child: and attach a copy 0f the Recognition of Parentage. If N0, why not? iv. Has Petitioner B signed the "Spouse's Non-Parentage Statement" for any of the Children listed at (i) above? D YES D NO If YES, state the name of the child: and submit a copy of the "Spouse's Non-Pare ntage State men ." 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 another marriage or relationship? D YES m NO If YES, the full name, date of birth and age of each child born prior to the marriage is: Full Name of Child and Date of Does Child Live Is Petitioner B Court- Age Birth with Pe titio ne r Ordered to pay Child B? Suppon for this C hild? LJ YES LI NO l_l YES Ll NO El YES E] NO [I YES [:1 NO L_l YES LJ NO Ll YES LI NO E] YES E] NO 1:] YES {:1 NO DtV1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 7 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM b. Has Petitioner B given birth during the marriage to a minor Child who is not a Child of Petitioner A? D YES E NO If YES, answer (i) , (ii), (iii) and ( iv): i. List the full 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: Full Name of Child and Date of Does Child Is Petitioner B Court- Age B irth Live with Ordered to pay Child Petitioner B? Support for this Child? L__l YES |_l NO Ll YES |_l NO D YES D No D YES El No ii. Is there a Court Order naming someone otherthan the Petitioner A as the father of the children listed in (i) above? D YES D NO If YES, submit a copy of the Order. The Order is for: Full Name of Children iii. Have Petitioner B and biological Father signed a Minnesota Recognition of Parentage (ROP) for any of the children listedin (i) above? D YES D NO If YES, state the full name of the child: and attach a copy of the Recognition of Parentage. If NO, why not? iv. Has the Petitioner A signed the "Spouse's Non-Parentage Statement " for any of the children listed at (i) above? D YES D NO If YES, state the name of the child: and submit a copy of the "Spouse's NonPare ntage Statement." If NO, why not? 16. Custody It is in the child's best interests and we agree that legal custody be granted as follows: (check one) m Joint legal custody to both parents D Sole legal custody to D PetitionerA D Petitioner B DIV1702 State ENG Rev 5/19 www.mncourtsgov/forns Page 8 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM It is in the child's best interests and we agree that physical custody be granted as follows: (check one) $ Joint physical custody to both parents D Sole physical custody to D PetitionerA D Petitioner B 17. Parenting Time a. It is in the best interests of the children that: Petitioner A's parenting time with the joint children be: (check one) unsupervised D supervised D reserved Petitioner B's parenting time with the joint children be: (check one) E; unsupervised U supervised D reserved If parenting time is unsupervised for both parents, skip to Question 18. b. supervised parenting time (Option 1) Supervision is necessary because unsupervised parenting time is likely 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 is in the best interests of the children that supervision of parenting time be arranged as follow: (State who should supervise parenting time, and if there is a cost involved, who should pay the cost, and any other important details) DN 1702 State BIG Rev 5/19 www.mncourtsgov/forms Page 9 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM C. Reserved Parenting time We agree that parenting time should be reserved because: 18. Public Assistance (Note: If either pers on is receiving public assistance fromthe State of Minnesotaor : applies forit after this proceeding is started, notice of this marriage dissolution action mustbe given to Publ'r Authority office. See Minn. Stat. § 518A.44) a. Petitioner A receives public assistance from the State of Minnesota: E Yes D No If YES, the assistance is from Hennepln County. (checkallthat apply) D MFIP in the amount of $ Qi Q6 er month D Tribal TANF in the amount of $ 0 sag "per month D General Assistance in the amount of $ Q' QQ per month fl Medical Assistance D Child Care Assistance D MinnesotaCare b. Petitioner B receives public assistance from the State of Minnesota: D Yes No If YES, the assistance is from County. (checkallthat apply) D MFIP in the amount of $ per month U Tribal TANF in the amount of $ per month D General Assistance in the amount of $ per month D Medical Assistance D Child Care Assistance D MinnesotaCare c. The joint children of the parties receive public assistance from the State of Minnesota: D Yes No If YES, the assistance is from County. (Check all that apply): D MFIP D Medical Assistance D Tribal TANF D MinnesotaCare D IVE Foster Care 19. Supple me ntal Se curity Income (SSI) Supplemental Security Income (SSI) is a Federal income supplement program It is available to low- income people if they are over age 65, or blind, or disabled. DIV1702 State ExiG Rev 5/19 www.rnncourts.gov/forms Page 10 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM a. Petitioner A receives Supplemental Security Income (SSI): M' N0 D Yes in the amount of $ per month. b. PetitionerB receives Supplemental Security Income (SSI): No D Yes in the amount of $ per month. c. The joint children of the parties 1'eceive(s) Supplemental Security Income (SSI): N0 D Yes in the amount 0f$ $ per month. What isthe name of the child receiving SSI? 20. Petitioner A's Employment a. Petitioner A is employed: m Yes D No b. Petitioner A is selfemployed: D Yes E No c. Petitioner A works at least 40 hours per week: E Yes D No If Petitioner A is unemployed or working less than 4O hours / week, answer these questions: i. Why is Petitioner A unemployed or working less than 4O hours / week? ii. What is Petitioner A's past work experience (type of jobs, hours, pay, length of time at the job) and what are Petitioner A's professional qualifications or licenses? d. Current Employlnent: (if PetitionerA currently has more than two jobs, use an attachment forthe additional jobs.) who Name of Petitioner A's Employer (If self-employed, list name and business address) "CM 'Muuk Employer's Street Address M 3% host mNL PM State 355%?! w City Zip Code Name of Petitioner A's Employer if self-employed, list name and business address) DIV 1702 State ENG Rev 5/19 www.mncourts.gov/forrns Page 11 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Employer's Street Address City State Zip Code Questions about Current Jobs 1" Job 2"" Job Is Petitioner A paid by the hour m hourly D salary D hourly D salary or salaried? What is the average number of hours Petitioner A works per <10 hours hours week? How much overtime pay does Petitioner A receive per week on average? $0.00 $ Does Petitioner A rec eive If Yes, how much was received If Yes, how much was in bonus es last year? received in bonuses last year? bonuses? $ $ DYes m No 15' Job How much does Petitioner A How much does Petitioner A DYes D No 2nd Job expect to receive this year? expect to receive this year? $ $ 21. Petitioner A's Income Source of Income Amount Per Month (or zero) before de ductions/taxes Self Employment Income 55 '0 per month Self Employment income means gross receipts minus costs of goods sold minus ordinary and necessary M business expenses]. Job with 3031 $ 91003 per month Monthly income froma job Ho rly wage xHours worked per week x433 (weeks per month) Second Job with v $ 0 ' 00 per month Third Job with $ 0 O C; permonth [3* I . Commissions from all jobs $ C) t 0 per month Divide the total armunt you expect this year by 12 to get a monthly average Unemployment benefits $ I (30 per montli Social Security Retirement, Survivors or Disability Income (RSDI) (do not include 881) $ 0 t O 0 per month Investment and Rental Income $ 0 t (l 6 per month Annuity payments $QQ . O 0 per month D|V1702 State ENG Rev 5/19 www.mncourtsgov/forms Page 12 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Pension or Disability from work or military $ per montli Worker's Compensation $ per month Court-ordered spousal maintenance received $ per month Other income $ per month List Source Add all of the above. Total monthly income $ Der month Enter the amount of child support Petitioner A is court-ordered to pay for any non-joint children $ per month Enter the amount of spousal maintenance Petitioner A is court-ordered to pay to a current or former spouse $ per month Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Petitioner A's retirement, disability, or other eligibility per month Which parent receives the payment for the child? D Petitioner A D Petitioner B 22. Living Expenses for the Family D a. Petitioner A and Petitioner B and their children are still living together. Current monthly living expenses for the family total $4,. _ OR E b. PetitionerA and Petitioner B are living separately. The monthly family living expenses before separation totaled $ OO . At this time, Petitioner A's separate monthly living expenses total $ {/fig , and Petitioner B's monthly living expenms total $ 900 . Of the total current monthly living expenses for PetitionerA, $ 31'10 amount is for expenses just for the children that live(s) with Petitioner A. Of the total current monthly living expenses for Petitioner B, $ -2 '20! '} is for expenses just for the children that live(s) with Petitioner B. 23. Expenses for Special Needs for the Children a. Is there a joint child of the parties who has special needs and extraordinary medical expenses? D YES fl NO If Yes, Name of child with special needs: DN1702 State ENG Rev 5/19 www.mncourts.gov/forms Page 13 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Describe the needs: b.Does Petitioner A's monthly living expense (stated at #22) include the special needs expenses for the child? D YES D NO c. Does Petitioner B's monthly living expense (stated at #22) include the special needs expenses for the child? D YES D NO 24. Petitioner B's Employment a. Is Petitioner B employed? YES D NO b. ls Petitioner Bselfemployed? D YES $ NO c. Is Petitioner B working at least 40 hours per week? E YES D NO If Petitioner B is unemployed or works less than 40 hours/week, answer these questions: i. Explain why Petitioner B is not workmg or why Petitioner B works less than 40 hours/week ii. What is Petitioner B's past work experience (type of jobs, hours, pay, length of time at the job) and professional qualifications or licenses? d. Current Employment: (If PetitionerBhas more than two jobs at this time, use an attachment for the additional jobs.) 0? WW Néme'of Petitioner B's Empby'er (If Self-Employed list n me and business address) \1o'\\ ohm 0mm Employer's Street Address EN Q Wilde (wow MW State 613%? City Zip Code DIV1702 State ENG Rev 5/19 www.mncourts.gov/forrns Page 14 of 50 27-FA-23-357 Filed in District Court State of Minnesota 2/16/2023 10:44 AM Name of Petitioner B's Employer (If Self-Employed list name and business address) Employer's Street Address City State Zip Code Questions about Jobs 1" Job 2"" Job Is Petitioner B paid by the hour or [fl] hourly LJ salary hourly LI salary salaried? What is the average number of hours hours hours Petitioner B works per week? é?" How much overtime pay does Petitioner B receive per week on $ QsOQ $ average? Does Petitioner B receive bonuses? If Yes, how much did If Yes, how much did Petitioner B receive in bonuses Petitioner B receive in DYes mNo 15'Job last year? bonuses last year? UYes mNo 2"dJob $ $ How much does Petitioner B How much does Petitioner B expect to receive this year? expect to receive this year? $ $ 25. Petitioner B's Income Source of Income Amount PerMonth (or zero) before de ductions/taxes Self Employment Income $ Ell O O per month Self Employment income means gross receipts minus costs of goods sold minus ordinary and necessary business expenses. Job with E CW = \I $ Q '0 OO per month Monthly income froma job wage xI-Iours worked per week x433 (weeks per month) Second Job with Hovrbly l $ per month Third Job with N (W $ O r 00 per month Commissions from all jobs $ (D v O per month Divide the total amount you expect this year by 12 to get a monthly average Unemployment benefits $ C.) ' O per month Social Security Retirement,