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Minnesota Petition With Children For The Dissolution of Marriage Form

In case of dissolving a marriage with minor children in the State of Minnesota, the Minnesota Petition With Children For The Dissolution of Marriage Form has to be completed and submitted.

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State of Minnesota 	 	 	District Court	
County of  	 	Judicial District: 	 	
 	 	Court File Number: 	 	
 	 	Assigned Judge: 	 	
 	 	Case Type: 	Dissolution with Children	
 
In Re the Marriage of: 
 
      	 	
Name of Petitioner (first, middle, last)  	Petition For Dissolution Of	 	
  	Marriage With Children	 	
and    
      	 	
Name of Respondent (first, middle, last)   
 
STATE OF MINNESOTA                  ) 
COUNTY OF      	)SS 	
       (County where Petition is signed) 
   
1. Information about Petitioner  	
Full Name: ______________________________________________________________________\
__ 	
           First                  Middle           Last 
 	
Address where you live:            	 	
       Street Address       Apt. No. 
 	
            	_______ 	
  City    County   State    Zip Code	 	
 	
Mailing address where you agree to receive papers for this case:  	 Same as above address OR  	
   ________________________________________________________________________\
 
     
                                          	 	
       Street Address       Apt. No. 	
                 	_______ 	
  City    County   State    Zip Code	 	
 
Date of Birth: ________________________           Petitioner is the 	 husband     	 wife. 	
   Month           Day           Year 	
                             
  List all of Petitioner’s former  or other names or write “None”:  
 
              	 	
                       First                     Middle        Last 
 
                                     	 	
 	         First                     Middle        Last 	
 
 
 
 
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 1 of 33

2.  Information about Respondent  
Full Name:             	 	
          First                 Middle              Last 
 
Address:              	 	
      Street Address              Apt. No. 
 	
                  	 	
      City        County      State      Zip Code 	
 
 Respondent's address is unknown to Petitioner. 	
Respondent’s Date of Birth: ________________________ 	
     Month           Day           Year 	
List all of Respondent’s former or other names or write “None”: 
             	 	
            	First                     Middle                      Last 	
              	 	
    First                     Middle        Last 
 
3. Our Marriage 	
  Petitioner and Respondent were married on: 	(month, day, year) 	      	, 
in the City of _____________________, C ounty of _______________________________, State of 
__________________________, Country of        
. 	
 	
4.  180 Day Requirement  	
Has Petitioner been living in Minnesota  for the past six (6) months?   	 YES     	 NO         	
Has Respondent been living in Minnesot a for the past six (6) months?   
    	 YES     	 NO      	UNKNOWN 	
 
5. Armed Forces 
 Is Petitioner an active duty member of the armed forces?      	 YES     	 NO  	
         If YES , has Petitioner been stationed in Minne sota for the past six (6) months?   	 YES    	 NO 	
 
Is Respondent an active duty member of the armed forces?   	 YES     	 NO    	Unknown 	
If YES, has Respondent been stationed in Minn esota for the past (6) months?     	YES   	NO   	
 	
6. Marriage Cannot be Saved  
         There has been an irretrievable br eakdown of my marriage relationship with Respondent and 
         the marriage cannot be saved.  	
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 2 of 33

7. Physical Living Situation  	
Do Petitioner and Respondent live together at this time?   	 YES     	 NO    	
If NO, the date we separated was:        .	 	
      	Month                 Day     Year	 	
          If  YES, why are you living together  at this time?       	
              
              	 	
 
8.     Other Proceedings 	
a. Has a separate court case for marriage disso lution, legal separation, custody, paternity or 
annulment already been started  by Petitioner or Respondent in Minnesota or  elsewhere?    	
  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 status or outcome of the case is:  	
 Open       	 Closed      	 I do not know    	
b. Has a County started a Support  case involving the Petitioner and the Respondent or their 
children?  	
 YES     	 NO     If YES, the case was started in ________________________ 
County in the State of ____________________ and the Court f ile number is       .           	
 A copy of the Support Order is attached, or the case is 	 Dismissed,  or  	 Pending. 	
 
9.      Protection or Harassment Order  	
Is an Order for Protection or a Harassment/Restraining Order  in effect regarding Petitioner and 
Respondent?   	
 YES    	 NO  	
If YES:  
a.  The  Order protects:    	 Petitioner    	 Respondent  	 the child(ren) and the Order was filed 
in        	
 County in        	State on 
    	
 date, and the Court f ile number is        	.  A copy of the 
Order is attached.       	
b.  Does the Order for Protection incl ude an order to pay child support?  	 YES    	 NO  	
 	
10.  Juvenile Court Case 
 Is a Juvenile Court case (child protection, delinquen cy or foster care) involving husband's and wife’s 
child(ren) taking place in Minneso ta or another state?     	
 YES     	 NO 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 3 of 33

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 Juvenile Court case is:          	
              .	 	
 
11.  Children Husband and Wife h ave Together (Joint Children) 	
“Child” means a living person under age 18, or under age 20 and still in high school.  
 
 a.  Are there any children born to or adopted by husband and wife  together, either before or during 
     the marriage?   	
 YES 	 NO       If YES,  	
Full Name of Child 	Date of Bi rth	Age	Child Currently Lives With 	
 	 	 	Petitioner       	Respondent       	Both parents  	
OR	_______________________(write in name) 	
 	 	 	Petitioner  	Respondent  	Both parents  	
OR 	________________________(write in name)	
 	 	 	Petitioner  	Respondent  	Both parents  	
OR 	________________________(write in name)	
 	 	 	Petitioner  	Respondent  	Both parents 	
OR 	________________________(write in name)	
 	 	 	Petitioner  	Respondent  	Both parents 	
OR 	________________________(write in name)	
 
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 husband and  wife together lived in Minnesota for the past 
     six (6)  months?      	 YES     	 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:                 	
             
             
             	 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 4 of 33

12. Adult Dependent Children   
 	Support can be ordered for a joint child over age 18 who cannot support him/herself because of a physical or   mental 
 condition.  
  Is there an adult joint child bor n to or adopted by Husband and Wi fe who is not able to support 
  himself or herself because of a  physical or mental condition?    	
 YES     	 NO 	
 
If YES, the full name, date of birth and age of each adult dependent is: 	
Full Name of Dependent 	Date of Birth 	Age 	
 	 	 	
 	 	 	
 	
13.    Pregnancy 	
a. 	 Petitioner   	 Respondent is the wife in this marriage. 	
b.      Is wife pregnant?    	 YES      	 NO   	UNKNOWN 	
    If wife is pregnant answer (i) and (ii): 	
    (i) The date the baby is due is          	 OR 	UNKNOWN                 
       	
Month       Day              Year	 	
(ii) Do Wife and Husband agree that husband is  the biological father of the unborn child?      	
 YES     	 NO 	
 If NO,  	 Wife   	 Husband claims husband is not the biological father of the child,  
  and Petitioner asks the Court to issue a sepa rate order setting a hearing date for after  	
 the birth of the child to determine  Paternity, unless appropria te Recognition of  
 Parentage documents are  signed by husband,  wife and the biological father after the 
 birth of the child. 
14.    Husband’s Children from Oth er Relationship (Non-Joint Children) 	
Does Husband have minor child(ren) from another marriage or relationship?  
    	 YES  	 NO   	  UNKNOWN             	
 If YES, the full name, date of birth and age of each child is: 	
Full Name of Child 
and Age 	Date of Birth 	Does Child Live with Husband? 	Is Husband Court-Ordered to pay 	
 Child Support for this Child?  	
 	 	 YES  	 NO 	      	 YES  	 NO 	
 	 	 YES  	 NO 	      	 YES  	 NO 	
 	 	 YES  	 NO 	      	 YES  	 NO 	
 	 	 YES  	 NO 	      	 YES  	 NO 	
 	 	 YES  	 NO 	      	 YES  	 NO 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 5 of 33

15.    Wife’s Children from Other Relationship  (Non-Joint Children) 	
 a.  Does Wife have minor child(ren)  born prior to the marriage from another marriage or           
     relationship?     	
 YES     	 NO   	 UNKNOWN   	
      If YES , the full name, date of birth and age of each child  born prior to the marriage is: 	
Full Name of Child 
and Age 	Date of Birth 	Does Child Live  with Wife? 	Is Wife Court-Ordered to pay 
 Child Support for this Child?  	
 	 	 YES  	 NO 	        	 YES  	 NO 	
 	 	 YES  	 NO 	        	 YES  	 NO 	
 	 	 YES  	 NO 	        	 YES  	 NO 	
 	 	 YES  	 NO 	        	 YES  	 NO 	
    
  b.  Has Wife given birth,  since marrying Husband, to a minor child who is not a      
      child of the Husband?       	
 YES    	 NO             	
       If  YES, answer (i) , (ii),   (iii) and ( iv): 	
(i)  List the full name, date of birth and  age of each child born to Wife since marrying 
Husband, who is not a child of the Husband: 	
Full Name of Child  and Age 	Date of Birth 	Does Child Live  with Wife? 	Is Wife Court-Ordered to pay 
 Child Support for this Child?  	
 	 	 YES  	 NO 	        	 YES  	 NO 	
 	 	 YES  	 NO 	        	 YES  	 NO 	
 	
(ii)  Is there a Court Order naming someone other  than the Husband as the father of the 
            child(ren) listed in (i) above?  	 YES      	 NO      	
      If YES, attach a copy of the Orde r. The Order is for: _______________________ 
        	           Full Name of Child(ren) 	
 	
(iii) Have the Wife and biological Father si gned a Minnesota Recognition of Parentage 
            for any of the children listed in (i) above?  	 YES      	 NO   	
   If YES, state the full name of the child:         	and 
attach a copy of the Rec ognition of Parentage.   	
  If NO , why not?         	
           	 	
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 6 of 33

(iv)    Has the Husband signed the “Husband ’s Non-Paternity Statement ” for any of the 
           children listed at (i) above? 	 YES    	 NO   	
           If YES, state the name of the child:             	 	
            and attach a copy of the "Husband's Non-Paternity Statement."  	
If NO, why not?         
           	 	
    	
16.   Parenting Time 
        Petitioner's parenting time with the joint children should be: (check one)  
   	 unsupervised     	 supervised   	 reserved 	
  Respondent's parenting time with the  joint children should be:  (check one) 
   	 unsupervised     	 supervised   	 reserved  	
If parenting time is unsupervised for both parents, skip to Question 17.  
 
For supervised	 parenting time answer a. and b.  For reserved	 parenting time, answer c. 	
     a.  Explain how unsupervised parenting time  is likely to endanger the child's  physical or  
          emotional health or impair the child's emotional development:        
                 	 	
             
             
             
             	 	
 b.  State who should supervise parenting time,  and if there is a cost involved, who should pay 
the cost, and any other important details:        
             
             
             	 	
 c.  Explain why parenting time should be reserved:           
             
             
             	  	
  
 
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 7 of 33

17.  Public Assistance from State of Minnesota 	
   If either party is receiving public assistance from the State of Minnesota or applies for it after this   
   proceeding is started, the Petitioner must give notice of this marriage dissolution action to the Support and  
   Collections office for the county paying the assistance. 
             
   a.   Does Petitioner receive public  assistance from the State of Minnesota?  	 YES    	 NO 	
 If YES, the assistance is from __________________ C ounty.  (Check all that apply): 
  	 MFIP in the amount of $___________per month   	
            	 Tribal TANF in the amount of $__________per month 	
              	General Assistance in the amount of $___________per month 	
            	 Child Care Assistance    	 MinnesotaCare   	 Medical Assistance 	
 
b.   Does Respondent receive public a ssistance from the State of Minnesota? 
        	 YES    	 NO  	 UNKNOWN 	
If YES, the assistance is from __________________ C ounty.  (Check all that apply): 	
 	 MFIP in the amount of $___________per month   	
            	 Tribal TANF in the amount of $__________per month 	
              	General Assistance in the amount of $___________per month 	
            	 Child Care Assistance    	 MinnesotaCare   	 Medical Assistance 	
   	
           c. Do the joint children of the part ies receive public assistance from the State of Minnesota? 	
  	 YES   	 NO   	 UNKNOWN 	
If YES, the assistance is from __________________ C ounty.  (Check all that apply): 
      	 MFIP   	 Medical Assistance   	 Tribal TANF   	 MinnesotaCare  	
      	IV-E Foster Care 	
18.    Supplemental Security 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. 	  	
a.     Does Petitioner receive Supplemental Security Income (SSI)? 	 NO    	 YES in the amount 
of $___________per month.  	
b.    Does Respondent receive Supplemental Security Income (SSI)? 	 NO    	 YES in the 
amount of $___________per month.  	
         c.      Do any of the joint children  of the parties receive Supplemental Security Income (SSI)?  
  	 NO    	 YES in the amount of $___________per month. Wh at is the name of the child  	
  Receiving SSI?____________________________________________________________ 
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 8 of 33

19.    School 	
Is Petitioner currently enrolled in school? 	 YES    	 NO  If Yes: 	
a.  The name of the school is                     .	 	
b.  The type of school is 	 High School    	College    	Vocational   	Other 	
c.  The type of degree exp ected is____________________________and the expected  
     graduation date is __________________________. 	
Is Respondent currently enrolled in school? 	 YES    	 NO  	 UNKNOWN   If Yes: 	
 a.  The name of the school is         .	 	
b.  The type of school is 	 High School    	College    	Vocational   	Other 	
c.  The type of degree expected is____________________________and the expected  
     graduation date is __________________________. 	
 
20.    Petitioner’s Employment 
         a.  Is Petitioner employed?   	 YES    	 NO     Is Petitioner Self-Employed?  	 YES    	 NO 	
         b.  Is Petitioner working at least 40 hours per week?  	 YES    	 NO   	
              If you are unemployed or wo rking less than 40 hours/week, answer these questions: 
i. Explain why you are not working or why you work less than 40 hours/week.       
              
              
              	 	
 ii. What is your past work experience (type of jobs , hours, pay, length of time at the job) and what are 
your professional qualifications or licenses?         
              
              
              
              	 	
 
  c.     Current Employment: 	(If Petitioner has more than two jobs at this time, use an attachment for the additional jobs.) 	
________________________________________________________________________\
____ 
Name of Petitioner’s Employer   (If Self-Employed, list name and business address)     	
 	
________________________________________________________________________\
____
Employer’s Street Address 
 
City                                                           State                                                   Zip Code 
 
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 9 of 33

Name of Petitioner’s Employer   (If Self-Employed, list name and business address)    	
 	
________________________________________________________________________\
____
Employer’s Street Address 	
 	
________________________________________________________________________\
____ 
City                     State          Zip Code 	
 
Questions about Current Jobs 	1st Job 	2nd Job 	
Are you paid by the hour or do you 
have a salary? 	hourly  	salary 	
 	
hourly  	salary 	
 	
What is the average number of hours 
you work per week? 	 
________________hours 	
 
________________hours 	
How much overtime pay do you 
receive per week on average? 	 
$_____________________ 	
 
$____________________ 	
Do you receive bonuses?  
 	Yes   	 No 	
If Yes, how much did you receive in  
bonuses last year? $_____________ 
How much do you expect to receive 
this year? $___________ 	
If Yes, how much did you receive in 
bonuses last year? $_____________ 
How much do you expect to receive 
this year? $___________ 	
 
21.  Petitioner’s Income 
       NOTE: There is a separate form called "Financial A ffidavit" which you must fill out, serve on your 
       spouse, and file with the court at the time you file this Pe tition.  You must attach proof of your 
       income to the Financial Affidavit.        	
 
If you do not have income in a category, enter zero (0).  Do not list public assistance benefits as income (e.g. 
MFIP, GA, SSI). 	
                     Source of Income          Amount Per Month ( before deductions/taxes)  
Self Employment Income                $________________ (or zero) 	
              	 Self Employment income means gross receipts minus costs of goods sold minus ordinary and 	
              Necessary business expenses. Attach Schedule "C"  from last year's tax return to this Petition. 	
Job with __________________________    $________________per month  
    Your 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 all jobs                $________________ per month 
               	Divide the total amount you expect this year by 12 to get a monthly average 	
 
Unemployment benefits          $________________ per month   	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 10 of 33

Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) 
                                                            $_________________per month  
Investment and Rental Income          $________________ per month 
Annuity payments    $________________ per month 
Pension or Disability from work  or military     $________________ per month 
Worker's Compensation    $________________ per month 
Court-ordered spousal maintenan ce you receive     $________________ per month 
 
Other income____________________________       $________________ per month 
                              	Identify Source 	
             
  Add all of the above.  Total monthly income 	             $ ________________ per month   	 	
 	
Enter the amount of child support  you are court-ordered  
     to pay for any nonjoint child(ren)                               \
          $________________per month  	
 	
Enter the amount of spousal maintenance you are court-ordered 
     to pay to your current or former spouse                                $_______________per month  
 
Enter the amount of Social Security or Veteran's  Benefits provided to a joint child because of 
      your retirement, disability, or other eligibili ty                      $________________ per month 
      If you entered an amount, which parent receives the payment for the child? 
   	Petitioner  	Respondent 	
 
 
   	
22.    Living Expenses for the Family 	
 a.  Petitioner and Respondent and our children ar e still living together. Our current monthly       
          living expenses for our family total $          .	
 	
 OR 	
 b.   Petitioner and Respondent are living sepa rately.  Our monthly family living expenses before 	
            we separated totaled $        .	 At this time, Petitioner's separate monthly  	
            living expenses total $____________, and Respondent's monthly living expenses total 
            $______________or 	 are unknown to Petitioner.   Of the total current monthly living  	
            expense for Petitioner, what dollar amount  is for expenses just for the children that live with  
            Petitioner?    $_________________.    Of  the total current monthly living expenses for  
  Respondent, $___________is for expenses just for th e children that live with Respondent, or 
 	
 this is UNKNOWN.  	
 
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 11 of 33

23. Expenses for Special Needs for the Children 
    a.  Is there a child of the parties who has special needs and extraordinary medical expenses? 
           	 YES  	 NO   If Yes,  	
      Name of child with special needs:                 	 	
      Describe the needs:           	
             
             	 	
  b.  Does Petitioner’s monthly living expense (stated at #22) include the special needs expenses for 
the child?  	
 YES  	 NO    	
  c.  Does Respondent’s monthly living expense (s tated at #22) include the special needs expenses 
for the child?  	
 YES  	 NO  	
24.    Respondent’s Employment 
           a.  Is Respondent employed?  	 YES  	 NO   	 UNKNOWN   	
           b. Is Respondent Self-Employed?  	 YES  	 NO   	 UNKNOWN 	
           c. Is Respondent  working at least 40 hours per week?  	 YES   	 NO  	 UNKNOWN 	
              If Respondent is unemployed  or works less than 40 hours/week, answer these questions: 
              i. Explain why Respondent is not  working or why Respondent works less than 40 hours/week 
              
              
              	 	
             ii. What is Respondent's past work e xperience (type of jobs, hours, pay, length of time at the job) 
and professional qualifications  or licenses?         
              
              
              	 	
c.  Current Employment: 	(If Respondent has more than two jobs at this time, use an attachment for the additional jobs.) 	
 	
________________________________________________________________________\
____ 
Name of Respondent’s Employer   (If Self-Employed list name and business address)     	
 	
________________________________________________________________________\
____
Employer’s Street Address 	
 	
________________________________________________________________________\
____ 
City                       State              Zip Code 	
 	
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 12 of 33

________________________________________________________________________\
___ 
Name of Respondent’s Employer  (If Self-Employed list name and business address)    	
 	
________________________________________________________________________\
____ 
Employer’s Street Address 	
 	
             	 	
City                       State              Zip	 Code 	
 	
Questions about Jobs 	1st Job 	2nd Job 	
Is Respondent paid by the hour or  
salaried? 	hourly  	salary 	
Unknown 	
hourly  	salary 	
Unknown 	
________________hours 	
Unknown 	
________________hours 	
Unknown 	
What is the average number of hours 
Respondent works per week? 
How much overtime pay does 
Respondent receive per week on 
average? 	 
$_____________________ 	
Unknown 	
 
$____________________ 	
Unknown 	
Does Respondent receive bonuses? 	
Yes   	 No   	Unknown 	
If Yes, how much did Respondent 
receive in bonuses last year? 
$___________ 
How much does Respondent expect 
to receive this year? $___________ 	
If Yes, how much did Respondent 
receive in bonuses last year? 
$_________ 
How much does Respondent expect 
to receive this year? $___________ 	
 
25.    Respondent’s Income 	
         	  Petitioner has no information about Respondent's income 	
  OR 
          	  Petitioner does not have detailed information about Re spondent's income, but has good 
reason to believe that Respondent's pay is $________________ per  	
 week  	month  	
year, with bonuses, overtime or commi ssions in the additional amount of 
$________________ per  	
 week  	month  	year.  This is Respondent's   	 Net 
Income (after taxes and deductions) or  	
  Gross Income (before taxes and deductions.) 	
OR 
         	  Petitioner has detailed information about Responde nt's income.  If this is true, fill out the  	
      income information below.   
  	               	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 13 of 33

If Respondent has no income in a category, enter zero (0). 	 Do not list public assistance benefits as income 
(e.g. MFIP, GA, SSI). 	
 
        Respondent's Source of Income             Amount Per Month ( before deductions/taxes) 
Self Employment Income                $___________________ (or zero) 
     Self Employment Income means gross receipts minus costs of goods sold minus ordinary and 
     necessary business expenses.	 A	ttach Schedule C from last year's tax return to this Petition, if available. 	
Job with______________________________  $ ___________________ 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 
Commissions from all jobs      $____________________ per month 
               	Divide the total amount expected this year by 12 to get a monthly average 	
Unemployment benefits         $____________________ per month  
Social Security Retirement, Survivors or Disability Income (RSDI)  
                                           (do not include SSI)   $____________________ per month  
Investment and Rental Income           $____________________  per month 
Annuity payments       $_____________________ per month 
Pension or Disability from work or military      $_____________________ per month 
Worker's Compensation       $_____________________ per month 
Court-ordered spousal maintenance received 
             by Respondent                                              \
  $____________________ per month 
 
Other income____________________________       $____________________ per month 
                              	Identify Source 	
             
  Add all of the above.    Total monthly income	  $ ____________________ per month   	 	
 
Enter the amount of child support Res pondent is court-ordered to  
  pay for any nonjoint child(ren)                         $____________________ per month  
 
Enter the amount of spousal maintenance Respondent is court-ordered 
            to pay to a current or former spouse                $____________________ per month 	 	
 
  Enter the amount of Social Secu rity or Veteran's Benefits provided to a joint child because 
       of Respondent's retirement,  disability, or other eligibility                           
         $_____________________ per month 
               If you entered an amount,  which parent receives the payment for the child? 
    	Petitioner  	Respondent 	
 
 	
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 14 of 33

26.  Child Care Costs 	
Are there child care costs for the joint children because of work or school	?	YES 	 NO  	
If YES, attach to this Petition  a receipt or signed letter from the child care provider showing the 
cost of child care,  and answer (a) (b) and (c):	
  	
 a.  How many of your joint children need child care? 	One 	 Two 	 Three 	 __________ 	
 	b.  How much does the daycare center(s) or babysitter charge  per month? $    	     
      	
(If you pay by the week, multiply the weekly charge by 4.33 to get the charge per month. If costs vary during the  
    year, use the total yearly costs and divide by 12.)  	
  c.    Who pays the child care costs?   
       Petitioner pays    $     	per month 	
                Respondent pays $     	per month 	
                  The County pays $     	per month through a subsidy or child care  
   assistance.   	
          If the County pays, who app lied for the child care assistance?  
     	Petitioner 	 Respondent 	There is no county assistance 	
    
27.    Health Care Coverage 	
a.  Minnesota Care and Medical Assistance are av ailable from the State of Minnesota for people 
who qualify. Who receives Minnesota  Care or Medical Assistance?  	
 Petitioner  	 Respondent  	 Joint Children  	 No one 	
b.   Does Petitioner currently have medical insurance? 	(other than MN Care or Medical Assistance)  	
  	 Yes  	 No. If no, skip to c. 	
 
    i. Where does Petitioner get the medical insurance? 
    	 through his/her employment 	
    	 buys private medical insurance 	
    ii. How much does the medical insurance cost? 
      $____________per month for single coverage 
      $____________per month for single plus  spouse (if this is offered) 
      $____________per month for family coverage 
    iii. Who is currently covered by this medical insurance? 
  	 Petitioner  	Respondent  	All the Joint Children  	Some of the Joint Children: 	
Name the joint children who are covered_____________________________________ 	 Nonjoint children	 	
 
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 15 of 33

c. Does Petitioner have dental insurance? 	(other than MN Care or Medical Assistance) 	 	
  	 Yes  	 No. If no, skip to d. 	
    i. Where does Petitioner get the dental insurance? 
    	 through his/her employment 	
    	 buys private dental insurance 	
    ii. How much does the dental insurance cost? 
      $____________per month for single coverage 
      $____________per month for single plus  spouse (if this is offered) 
      $____________per month for family coverage 
    Or,       	 Dental is included in the medical insurance costs. 	
    iii. Who is currently covered by this dental insurance? 
  	 Petitioner  	Respondent  	All the Joint Children  	Some of the Joint Children: 	
Name the joint children who are covered____________________________________ 	 Nonjoint children	 	
 	
d.  Does Respondent have medical insurance? 	(other than MN Care or Medical Assistance)  	
   	Yes  	No  	Unknown. 	If No/ Unknown, skip to e. 	
    i. Where does Respondent  get the medical insurance? 
    	 through his/her employment 	
    	 buys private medical insurance 	
    ii. How much does the medical insurance cost? 
      $____________per month for single coverage 
      $____________per month for single plus  spouse (if this is offered) 
      $____________per month for family coverage 
    iii. Who is currently covered by this medical insurance? 
  	 Petitioner  	Respondent  	All the Joint Children  	Some of the Joint Children: 	
Name the joint children who are covered____________________________________ 	 Nonjoint children	 	
 
e. Does Respondent have dental insurance? 	(other than MN Care or Medical Assistance)  	
    	 Yes  	 No  	 Unknown   	If No/ Unknown skip to f. 	
    i. Where does Respondent  get the dental insurance? 
    	 through his/her employment 	
    	 buys private dental insurance 	
    ii. How much does the dental insurance cost? 
      $____________per month for single coverage 
      $____________per month for single plus  spouse (if this is offered) 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 16 of 33

$____________per month for family coverage 
    Or,       	 Dental is included in the medical insurance costs. 	
 
    iii. Who is currently covered by this dental insurance? 
  	 Petitioner  	Respondent  	All the Joint Children  	Some of the Joint Children: 	
Name the joint children who are covered_____________________________________	 Nonjoint children	 	
 
f. If the joint children are without  health care coverage, is coverage available for purchase through 
Petitioner's or Respondent's employer? 	
 YES  	 NO  	The children currently have health 
coverage     	
 
 	
28.    Spousal Maintenance  	
a.    Does Petitioner need spousal maintenance from Respondent?  	 YES  	 NO     If  YES, 
Petitioner is ______ years of age, Petitioner and Respondent  have been married for ______ 
years.  Petitioner has th e following education: _______________________________. 
Petitioner’s gross monthly income totals  $ _____________ , Petitioner’s monthly expenses 
total  $      	
, and Petitioner is not able to maintain the standard of living 
established during the marriage because:        	
             
             	. 	
b.  Does Respondent need spousal maintenance from Petitioner?  	 YES  	 NO    If  YES, 
Respondent is ______ years of age, Petitioner  and Respondent have been married for _______ 
years.  Respondent has th e following education: _____________________________________ 
Respondent’s gross monthly income  totals $ _____________ , Respondent’s monthly 
expenses total  $      	
, and Respondent is not able to  maintain the standard of 
living established during the marriage because:        	
             
             	 	
________________________________________________________________________\
___. 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 17 of 33

29.   Vehicles 
         	Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles etc. 	
          owned by husband or wife together or separately, including vehicles purchased after separation: 	
 
Does Petitioner own a vehicle?  	 YES   	 NO     	
Does Respondent own a vehicle?  	 YES   	 NO   	 UNKNOWN 	
List all vehicles owned by husband or wife together or separately: 
Type of 
Vehicle  (car, 
boat, truck etc.) 	Year/Make/ 	
Model  	
Name(s) on 	
Title 	
Value 	Balance Owed 	Monthly 
Payment 	
 	 	 	$ 	$ 	$ 	
 	 	 	$ 	$ 	$ 	
 	 	 	$ 	$ 	$ 	
 	 	 	$ 	$ 	$ 	
 
30. Marital Property 
  Marital property means almost anything that you or  your spouse now own that was received or bought during 
the marriage, even during th e times you were separated.	
  Marital Property includes household goods, 
furniture, jewelry, boats, real estate a nd other things.  Marital property does  not include a gift or inheritance 
received by one spouse  alone. 	
 	
Has the marital property been divided alre ady to the Petitioners’ satisfaction?   	 YES   	 NO  	
If NO, Petitioner requests the followi ng marital property:       
              	 	
________________________________________________________________________\
________ 
________________________________________________________________________\
________ 	
 
31.    Non-Marital Property 	
Non-marital property means: (1) anything that you or  your spouse owned before the marriage; (2) anything 
that you or your spouse received as a gift, bequest, devise, or inheritance,  to you or your spouse alone	
; (3) 
anything that you or your spouse got in trade or in exchange for your non-marital property; (4) anything that 
is an increase in the value of non-marital property; (5) anything you or your spouse received after the 
valuation date set by the court; or (6) anything  defined as non-marital property by a valid antenuptial 
contract.   	
 
a.  Does Petitioner have non-marital property?     	 YES   	 NO  	
If YES, list Petitioner’s non-marital property:         
             
             	 	
         
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 18 of 33

b.     Does Respondent have non-marital property?    	 YES    	 NO  	 UNKNOWN 	
If YES, list Respondent’s non-marital property:             
             	 	
________________________________________________________________________\
___. 	
32.  Cash & Accounts – Not including Pension and Employer-Funded Retirement Accounts 
 Does Petitioner have money in banks, savings, cash or investments?   	 YES   	 NO    	
   Does Respondent have money in  banks, savings, cash or investments? 	YES 	 NO 	UNKNOWN 	
If YES,  	
  a.      List all accounts owned by you alone, your spouse alone, or owned by both of you jointly 
including those opene d after separation.	
  “Type of account” means check ing, savings, money market 
accounts, certificates of deposit, stocks, bonds,  stock options, mutual funds, savings bonds, and 
Treasury Bills, etc. 	
         Do not include Pension or Empl oyer-Funded Retirement Accounts, which are listed at #36.  	
Financial 
Institution 	Type of Account 	Account # 	
Last 4 digits only 	
Amount 	Belongs to: 
(name on account) 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
       	b.   List cash not listed at a.: 	
  Petitioner has cash in the amount of $        .	 	
      Respondent has cash in the amount of $         	OR  	UNKNOWN. 	
33.    Business Interest 	
Does Petitioner have an inte rest in a business?     	 YES     	 NO  	
Does Respondent have an in terest in a business?  	 YES     	 NO    	UNKNOWN 	
If YES, the name of the business is ____________________________, the address is 
________________________________________________________________________\
________
and the value is $________________.  How did you  arrive at this value?       
              
              	 	
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 19 of 33

34.    Manufactured Home 	
Does Petitioner own a manufactured home?     	 YES     	 NO  	
Does Respondent own a manufactured home?  	 YES     	 NO    	UNKNOWN 	
   If either Petitioner or Respondent own a manufactured home, together or separately, complete   
   the following information: 
a.   Address of the manufactured home:                	 	
        in the city of            ,	 state of          	 	
   b.  What type of home is it?   (single, double-wide etc.)      	 	
   c.   Whose name(s) is on the title?                 	 	
   d.   When was the home purchased?                 	 	
   e.    What was the purchase price?    $                 	 	
   f.    What is the current values of the home?  $              	    	
g.   How did you arrive at that amount as the current value?           	
             	 	
    h.  How much money is still owed on the home?  $             	 	
    i.   If money is owed on the home, who is the mone y owed to?      	 	
    j.  Do you own the land the home sits on, or do you rent a lot?   	 Rent     	 Own  	
         Note:  If you own the lot, you must list the land at Paragraph 35. 	
35.  Real Property -  Land, Buildings, Contracts for Deed 
         	All real property now owned by Petitioner or Respondent t ogether or separately must be listed. Include real 
property acquired before the marriage, dur ing the marriage, and after separation.	
 	
a.  Do Petitioner and Respondent jointly	 own real property?     	 YES    	 NO     	
b.  Does Petitioner own real property solely in his/her own name or with someone other than 
Respondent?    	
 YES   	 NO      	
c.  Does Respondent own real property solely in hi s/her own name or with someone other than 
Petitioner?    	
 YES   	 NO 	 UNKNOWN 	
d.  How many properties are owned by  you and your spouse in total? 	 None 	 One  	 Two  	
    	 Three  	 _______ 	
If you or your spouse own real pr operty, separately or together, complete the following 
information about the property.  If there is mo re than one piece of real property,  photocopy 
and complete a Real Property Information page  for each piece of property.  Staple the 
additional sheets to this Petition, and la bel each sheet "Attachment to Petition of 
____________________(your name)" 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 20 of 33

Real Property Information 
1. Real Estate belongs to: (List full names of all owners)_____________________________________ 
________________________________________________________________________\
________ 
2. Legal Description is: (The full legal description  must be included.  Copy the legal description from 
the deed. Do not use the property ta x statement legal description.   If the legal description is long, 
you may use an attachment.  Type or print neatly.) 
________________________________________________________________________\
__________
________________________________________________________________________\
__________
________________________________________________________________________\
__________
________________________________________________________________________\
__________
________________________________________________________________________\
__________ 
3.  Street Address of th e real property is:  
________________________________________________________________________\
________ 
        City______________________________________State______________Zip\
 Code______________ 	
  The property is in_____________________________________County. 
4.   Purchase date_________________(month , day,   year) and purchase price:$      _______	 	
5.   Mortgages or loans:  (List all mortgages and loans on the property) 
         	 There are no mortgages or loans on this property. 	
 1st Mortgage: Amount currently owed  $     	and name of lender   	
             	   
2	
nd Mortgage: Amount currently owed $     	and name of lender   	
                                   	 	
Other mortgages or loans:         
             	 	
6.  Current Market Value of this property:        $___________________________________ 	
 How did you arrive at this value?         
              
              	 	
7.  This property is the ho mestead:  _______Yes     _________No 
 
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 21 of 33

36.  Retirement Plans   	
a.  Does Petitioner  have a retirement account? (I RA, 401(k), 403(b) or other) 
  	 YES  	 NO    If YES: 	
a) The account number is: (last  4 digits only)       	 	
b) The name of the bank that has the account is:           	 	
c)  The current account balance is:         	 	
b.  Has	 Petitioner , or Petitioner’s past or present em ployer, union, or other group, paid money 
into a pension, profit sharing, or other retirement plan for Petitioner?  	
 	 YES  	 NO 	
If YES:    
a) The name of the plan is:____________________________________________________ 
b)  The employer, union or group provi ding the plan is:          	 	
c) The date Petitioner  began working at the  job or joined the union or group plan is: 	
            	 	
d) The type of  plan is: (e.g. defined  benefit, defined contribution)        	
            	 	
e) The present value of the pens ion or plan is:       	 	
c.  Does Respondent  have a retirement account?  (IRA, 401(k), 403(b) or other) 
  	 YES  	 NO  	 UNKNOWN 	
If YES: 
a) The account number is: (last  4 digits only)       	 	
b) The name of the bank that has  the account is:        	 	
c) The current account balance is:         	 	
d.  Has	 Respondent , or Respondent’s past or present  employer, union, or other group, paid 
money into a pension, profit sharing, or other retirement plan for Respondent?  	
  	 YES  	 NO  	 UNKNOWN 	
If YES , and it is a  Pension, Profit-Sharing, or other Retirement Plan:    
a)   The name of the plan is:         	 	
b)   The employer, union or group providing the plan is:          	 	
c)   The date Respondent began working at th e job or joined the union or group plan is: 
                  	 	
d)   The type of plan is: (e.g. define d benefit, defined contribution)        	
            	 	
  e)    The present value of the pension or plan is: ___________________________________ 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 22 of 33

37. Debts  	
Does Petitioner have debt?      	 YES    	 NO  	
Does Respondent have debt?   	 YES    	 NO    	 UNKNOWN  	
If YES, list debts in your name, your spouse’s na me and in both names jointly.  Include unpaid 
debts from before the marriage date, during the  marriage, and after separation.  Fill in all 
information completely and attach a nother sheet of paper if necessary. 
 
Money is owed 
to: 	Money was used  for: 	Whose Name is on the Account and When was the Debt  Incurred? 	
Name                        Date 	
Balance Owed 	Monthly 
Payment 	
  
 	
 	 	$ 	$ 	
 
  	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
  
 	
 	 	$ 	$ 	
 
 	
 	 	 	 	
  	 	 	$ 	$ 	
 	Total Debt 	$ 	$ 	
 
38. Name Change 	
Does Petitioner want to change his/her name? 	 YES 	 NO If  YES, answer (a) through (c) 
below: 	
a.   Petitioner’s name should be changed to         	   	
                                                          First                            Middle                             Last 	
  Is this name a former legal name or maiden name?   	 YES   	 NO        If  NO, the reason 
Petitioner wants to change  to this name is: _________________________________________ 	
 _______________________________________________________________________\
_____ 
________________________________________________________________________\
____ 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 23 of 33

b. Petitioner has no intent to defraud or mi slead anyone by changing his/her name:   	
 	 True   	 False 	
c.  Has Petitioner been convicted of a felony?  	 YES    	 NO          If YES, answer i. and ii: 	
   	 i.   Petitioner has given notice of this requ est for name change to the proper authority as 	
                required by Minn. Stat. Section 259.13.  (See Felon Name Change Instructions) 	
 ii.  Petitioner has attached to this Petition an  Affidavit of Service of the Notice marked 	
                 Exhibit “A”.   	
39.   Other    Include other facts you thi nk the Court should know. 	
________________________________________________________________________\
________ 
________________________________________________________________________\
________
________________________________________________________________________\
________
________________________________________________________________________\
________ 	
 	
BASED UPON THE ABOVE INFORMATION, Peti tioner requests that the Court issue a 
final judgment and decree granting the following relief: 	
 	
1.  Dissolving the bonds of matrimony between Petitio ner and Respondent to end the marriage.  
2. Legal Custody : 	Legal Custody means which parent(s) have a say in the major decisions regarding    
 the child(ren)’s life including education,  religious upbringing and medical treatment. 	
 	
Granting legal custody of each minor child of the parties as follows: 	
Name of Child 	Granting Legal Custody: 	
 	 Solely to Petitioner   OR  	 Solely to Respondent  OR  	 Jointly to 
both parties.   	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 24 of 33

3.  Physical Custody: 	Physical custody identifies which parent(s) will handle the routine daily care and control 
 of the  child(ren).     	
     Granting  physical custody of each of the minor children of the parties as follows: 	 	
Name of Child 	Granting Physical Custody: 	
 	 Solely to Petitioner   OR  	 Solely to Respondent  OR  	 Jointly to 
both parties.   	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 	 Solely to Petitioner    OR    	 Solely to Respondent  OR      	 Jointly 
to both parties.  	
 
 
4.       Parenting Time 
  a.  Petitioner's parenting time shall be:    	 Unsupervised  	 Supervised   	 Reserved  	
  b.  Respondent's parenting time shall be: 	 Unsupervised  	 Supervised   	 Reserved  	
  c.   Parenting Time Schedule shall be as follows: 
   (Clearly explain the time each	 parent will spend with each child. Include the time (o'clock) when 
  the child will transfer from one parent to the ot her. If you want the order to say who will pick up 
  and drop off the child, incl ude that under "Other.")  	
 
Regular schedule: 
Monday through Friday:            
             
             
             
             
             	 	
Weekends:              
             
             
             	 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 25 of 33

Summer (if you want a different schedule in summer)      
             
             
             	 	
Telephone contact with the child(ren):  	 Unlimited   or   	  Only at certain times as follows:  
(describe the days and times when the parent  and child(ren) may have telephone contact)   	
             
             	 	
Exceptions to the Regular Schedule: 
You can have a different schedule for holidays, school release days, and birthdays. If you do not 
want a different schedule, leave it blank.  
 
School Release days or breaks dur ing the school year      
             
             	 	
Any school release day schedule will supercede the regular parenting schedule.	  	
 
Birthdays (child's birthday, parent's birthday)       
             
             	 	
Holidays            	  	
             
             
             	        
Any holiday or birthday schedule will supercede th e regular and school release parenting schedule. 	
 	
Other               
             
             	 	
 
d. Under the above Schedule: 
The children are with Petitioner:              The children are with Respondent: 	
 less than 10% of the time         	 less than 10% of the time 	
 10-45% of the time         	 10-45% of the time 	
  45.1-50% of the time         	  45.1-50% of the time 	
  more than 50% of the time       	  more than 50% of the time 	
 
 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 26 of 33

5. Child Support     
    Ordering the payment of child s upport based on each parent's income. If either parent fails to  
    provide income information, the court will se t child support based on the available evidence  
    and Minnesota law.     
  
6.         Health Care Coverage for  the Joint Children  
 Choose a, b, or c. 
 	a. 	 Petitioner  	 Respondent shall provide medical  insurance for the joint minor child(ren): 
            	
 through his/her employer or union  OR 	
     	 by obtaining and paying for private insurance. 	
       	 Petitioner   	 Respondent shall provide dental  insurance for the joint minor child(ren):  
     	
 through his/her employer or union OR 	
     	 by obtaining and paying for private insurance. 	
                  The other parent must cont ribute to the costs of health coverage as required by law. 	
OR         	
b. If Medical Assistance or Minnesota Care is open for the child(ren), ordering 	
         the non-custodial parent  to ma ke a sum certain payment as reimbursement through  	
   income withholding through the Minnesota Child Support Payment Center.        	
OR          	
 c. Reserving the issue of medical and dental insurance for the minor children. 	
      	 d. Other:  ____________________________________________________________   	
         ________________________________________________________________________\
 
           ________________________________________________________________________\
. 
 	
7.  Unreimbursed Medical and Dent al Costs for the Children  	
"Unreimbursed medical and dental costs" are expenses not  covered by insurance, not paid by medical assistance, 
and not paid by the State of Minnesota. Examples include  deductibles, co-pays, and procedures not covered by 
insurance or assistance.   Choose a. or b. 	
 	 a. Ordering each parent to pay a share of the  unreimbursed medical and dental costs for the  	
           child(ren) of the parties, based on the relative incomes of the parties;   OR 	
 	  b. Reserving the issue of unreimbursed medical and dental costs. 	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 27 of 33

8.  Medical and Dental Insurance for the Parties  
 	  a.  Ordering each party to provide for his or her own     	 medical    	 dental insurance. 	
 	 b.   Ordering ____________________________(full name) to provide   	 medical 	 dental 
insurance for ______________________________________________ (full name). 	
 c.   Allowing____________________________(full name), at his/her own expense, to  continue the dependent coverage available unde r the other party’s insurance plan, pursuant 
to federal and state statutes. 
 d.   Reserving the issue of medical a nd dental insurance for the parties.  	
9.  Child Care Expenses  
 	 a.  Ordering  Petitioner and Respondent to  each pay a share of the monthly child care  	
                      expenses, according to Minnesota law;  OR 
 	  b. Reserving the issue of child care expenses. 	
 
10. Spousal Maintenance 
 	  a.   Maintenance is denied to Petitioner and Respondent.  	
 	  b.   Reserving the issue of maintenance. 	
 	  c.   Ordering 	Petitioner 	 Respondent to pay spousal maintenance to 	Petitioner	 Respondent. 	
11. Vehicles 
  Awarding the vehicles as follows  and ordering the party receiving the vehicles to pay for any loans 
or insurance for such vehicle: 	
Year / Make / Model 	Awarded to: 	
 	 	
 	 	
 	 	
 	 	
 	 	
 
 
 
 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 28 of 33

12. Marital Property 
  Dividing the parties’ marital property,  household goods, furniture and furnishings either:  	
  a.  As currently divided OR 
 b.  As follows (attach additi onal page if necessary): 	
To Petitioner:            
            
            	 	
To Respondent:            
            
            	 	
 	
13. Non-Marital Property 
  Dividing the parties non-marital property  
 	  a.  As currently divided  OR 
  b.  As follows (attach addi tional page if necessary): 	
To Petitioner:            
            
            	 	
To Respondent:            
            
            	 	
14. Cash and Accounts  
  a.  Awarding the savings, and investments as follows: 	
Institution 	Type of Account 	Account # 	
(Last 4 digits only) 	
Amount 	Awarded to 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 	 	XX 	$ 	 	
 
         b.  	 Awarding any cash not included  in a. above to the party who currently has the cash OR 	
   	 Awarding the cash as follows:         	  	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 29 of 33

15.  Business 	
 	 None  OR 	
 	 Awarding the parties’  business as follows:  ___________________________________________ 
________________________________________________________________________\
_______ 
________________________________________________________________________\
_______
             	
 	
16.    Manufactured Home 	
        	 None  OR 	
   	  Awarding the manufactured home located at :             	 	
                                                street address 	
             	  	
     city                                                                     state 
 
to 	 Petitioner   	 Respondent.   The debt on the manufactured home owed to:     	
           	shall be paid by  	
 Petitioner   	 Respondent. 	
 	
17.  Real Property 
           	 None  OR 	
       	 Awarding solely to  	 Petitioner   	 Respondent  all right, title, and interest of husband  	
  and wife in the real property  located at: 
 Street address_________________________________________________________________\
__ 
 in the City of       	
, County of ___________________________, 
 State of     	
, which has the following legal description: ______________ 	
________________________________________________________________________\
_______ 
________________________________________________________________________\
_______ 
with the following mortgages and loans to be  paid, after the divorce is final, by    	 Petitioner   	
  	 Respondent: 	
1st Mortgage: Amount currently owed: $     	and name of lender:     	
             	 	
2nd Mortgage:  Amount currently owed: $     	and name of lender:     	
             	 	
  and  subject to the following liens or other agreements:  
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 30 of 33

A lien in favor of 	 Petitioner    	 Respondent in the amount of $        .	
  Other request regarding the property:  (describ e the request fully)       	
             
             
             
             
            	 
             	
18.  Additional  Real Property 	
 	 None  OR  	
 	 Awarding solely to  	 Petitioner   	 Respondent  all right, title,  and interest of husband and 
  wife in the real property  located at: 	
 Street address_________________________________________________________________\
__ 
 in the City of       	
, County of ___________________________, 
 State of     	
, which has the following legal description: ______________ 	
________________________________________________________________________\
_______ 
________________________________________________________________________\
_______ 
with the following mortgages and loans to be  paid, after the divorce is final, by    	 Petitioner   	
  	 Respondent: 	
1st Mortgage: Amount currently owed: $     	and name of lender:     	
             	 	
2nd Mortgage:  Amount currently owed: $     	and name of lender:     	
             	 	
  and  subject to the following liens or other agreements:  	
 	 A lien in favor of 	 Petitioner    	 Respondent in the amount of $        .	 	
 	  Other request regarding the property:  (describ e the request fully)       	
             
             
             
             	 	
  
 
 
         	
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 31 of 33

19.       Retirement Funds 
            a.  Awarding Petitioner’s pension, profit sharing, retirement plan, I.R.A., or 401(k) or other    
  retirement fund as follows:  	
  100% to Petitioner     OR 
  Dividing Petitioner's retirement benefits fa irly and equitably between the parties.  	
  
  b.  Awarding Respondent’s pension, profit shari ng, retirement plan, I.R.A.or 401(k) or other 
  retirement fund as follows:  	
  100% to Respondent  OR 
  Dividing Respondent's retirement benefits fairly and equitably between the parties.  	
 
20. Debts 
 	  a.  Dividing the debts as follows and ordering  each party to hold the other harmless from any  
responsibility for the debts so divided.   Include all debts listed at 37 above. 	
Debt Owed To: 	To Be Paid By: 	
 	 	
 	 	
 	 	
 	                	
 	 	
 	 	
 	 	
 	 	
 	 	
 	 	
 	  b.   Ordering that each party is solely responsible for paying any other debts incurred solely by        
him or her and ordering each party to hold the  other harmless from any responsibility for 
such separately incurred debts. 	
 
21.  Name Change 
 	
 Petitioner is not requesting a name change;  OR 	
  	
 Changing Petitioner’s name to:            	 	
             First                                          Middle                                         Last 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 32 of 33

22.Other:_______________________________________________________________________\
______
________________________________________________________________________\
_____________
________________________________________________________________________\
_____________
________________________________________________________________________\
_____________
________________________________________________________________________\
_____________ 
       
23.  Ordering such other relief as the  Court deems just and equitable. 
24.  READ and SIGN the Verification and Acknowledgments.  
 
STATE OF MINNESOTA      ) 
      )  SS 
COUNTY OF      	) 	
          (County where Petition is signed) 
Verification and Acknowledgments 
a.  I have read this document.  To the best of my  knowledge, information and belief the information 
contained in this document is well grounded  in fact and is warranted by existing law. 
b. I have not been determined by any Court in Minne sota or in any other State to be a frivolous 
litigant and I am not the subject of an Order prec luding me from serving or filing this document. 
c.  I am not serving or filing this  document for any improper purpose,  such as to harass the other 
party or to cause delay or needless increase in  the cost of litigation or to commit a fraud on the 
Court. 
d.  I understand that if I am not telli ng the truth or if I am misleading  the Court or if I am serving or 
filing this document for an improper purpose, the  Court can order me to pay money to the other 
party, including the reasonable expenses incurred by the other party because of the serving or 
filing this document, Court costs,  and reasonable attorney’s fees.  I understand that I could also be 
prosecuted for perjury if I am not  telling the truth in my Petition. 
 
 
DATE:    /   /  	        	 	
        Month       Day            Year             Petitioner’s Signature   
                     ( Sign only	 in presence of notary public) 	
 	
Mailing Address (Street):       	 	
  City, State 	 	
 Zip Code:        	 	
       Telephone:  (             )        	 	
Subscribed and sworn to before me this  
______day of _____________, ______. 
_______________________________ 
Notary Public or Court Clerk 
DIV802 State  ENG  Rev 1/07    www.mncourts.gov/forms  Page 33 of 33
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