MINNESOTA DISSOLUTION QUESTIONNAIRE
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READ THE FOLLOWING CAREFULLY: Please fill out this form as completely as possible. If a question does not apply to your situation, answer “N/A” (not applicable). If you need additional space for an answer, you may use the back of a page.
YOUR PERSONAL INFORMATION
Your full name:_________________________________________________________________
Street address:__________________________________________________________________
City:________________________ State :_______ Zip:_________ County:_________________
Address to which mail should be sent:_______________________________________________
Home phone:(______)______________Work phone:(______)_______________ ext._________
Cell/pager: (_______)___________ E-mail:__________________________________________
ATTORNEY/COURT INFORMATION
Are you or your spouse being represented by an attorney? If so, please provide the following information:
| |Your attorney |Your spouse’s attorney |
|Name of Attorney | | |
|Address of Attorney | | |
|Phone number | | |
|Fax number | | |
Are there any cases/actions currently pending (whether actually filed with the court or not) regarding the following matters (check all that apply)?:
__ dissolution __ child support __ custody __ child protection __ OFP/TRO __ other
Give details below of all pending actions:
|Type of case/action |What county/state? |Court File No.: |What is the current status |
| | | |(pending, order issued, etc.) |
| | | | |
| | | | |
PLEASE BRING COPIES OF ANY EXISTING COURT ORDERS/JUDGMENTS REGARDING THE ABOVE CASES/ACTIONS TO THE MEDIATION SESSION.
MARRIAGE INFORMATION
Date of Marriage:____________ Place of Marriage:________________________________
(city county state)
Did you or your spouse sign a pre-marital (antenuptial) agreement? yes/no (circle one)
Have you and your spouse separated? yes/no (circle one) If so, when?_____________________
Describe any history of domestic abuse in your marriage relationship, noting any court or law enforcement involvement:________________________________________________________
_____________________________________________________________________________
EDUCATIONAL INFORMATION
| |YOU |YOUR SPOUSE |
|Past: Institutions attended starting from high | | |
|school including degrees obtained and years of | | |
|attendance | | |
|Present and Future: Institution attending/to be | | |
|attended, degree to be obtained and years to obtain | | |
CHILDREN
Children of this relationship:
|Full Name |Birthdate |Social Security Number |In whose physical custody? |
| | | | |
| | | | |
| | | | |
Describe how and by what method paternity was established on the above children?__________
_____________________________________________________________________________
Are you, or the other party, pregnant? _______ If so, what is the due date?_________________
Physical or emotional disabilities of children:_________________________________________
______________________________________________________________________________
Children not of this relationship:
|Full Name |Birthdate |Social Security Number |Whose child and in whose custody? |
| | | | |
| | | | |
| | | | |
COMMUNICATION
By what method do you and the other party currently communicate regarding the child(ren)?
____________________________________________________________________________
What is your desired method of communication regarding the child(ren)?
______________________________________________________________________________
CUSTODY
Has physical and/or legal custody been established via a court order? __________ If so, attach a copy of the order.
What is your desired arrangement regarding physical custody of the child(ren)?______________
______________________________________________________________________________
What is your desired arrangement regarding legal custody of the child(ren)?_________________
______________________________________________________________________________
PARENTING TIME SCHEDULE
Describe the existing parenting time schedule regarding the child(ren) involved in this matter (attach a copy of any existing order regarding visitation/parenting time:____________________
______________________________________________________________________________
Describe your desired parenting time schedule:
Reasonable
24 hour notice
Restricted. Describe restrictions:___________________________________________
Specific schedule
_____ Alternate weekends from ________ Friday to ________ Sunday _____ Other:____________________________________________________________
Holiday Schedule
|HOLIDAY |ODD YEARS WITH |EVEN YEARS WITH |COMMENTS |
| |(Mother/Father) |(Mother/Father) | |
|New Year’s Day | | | |
|Easter | | | |
|Mother’s Day | | | |
|Memorial Day | | | |
|Father’s Day | | | |
|July 4th | | | |
|Labor Day | | | |
|Halloween | | | |
|Thanksgiving | | | |
|Christmas Eve | | | |
|Christmas | | | |
|Child birthdays | | | |
In the space below, provide any additional information you would like the mediator to know regarding the minor child(ren), the desired schedule, concerns about the other party (home, significant other, other children, job, etc) or other factors such as work schedules, distance between parental homes, etc. which you believe have an effect on parenting time with the other child:________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PRESENT EMPLOYMENT INFORMATION
*Complete information for all present jobs or sources of income
| |YOu |OTHER PARTY |
|Name/address of employer | | |
|Job Title/Description | | |
|Length of time with this employer | | |
|Benefits provided (specify): | | |
|Medical | | |
|Dental | | |
|Pension/401K | | |
|Life Insurance | | |
|Other | | |
|Hours worked per week | | |
|Other jobs/sources of income (provide | | |
|information as above) | | |
| | | |
| | | |
PREVIOUS EMPLOYMENT INFORMATION
*Complete information for all jobs held within last 5 years, not including present job
| |Employer |Job Held |Salary |
|YOU | | | |
| | | | |
INCOME INFORMATION
Please attach proof of income, if possible (paystub, etc.)
YOUR GROSS INCOME (before taxes or other deductions):
|Monthly Income Received |Amount |Monthly Income Received |Amount |
|Salary and Wages (before deductions) |$ |Child’s Derivative Social Security or Veterans’ Benefits |$ |
|Commissions |$ |Military and Naval Retirement |$ |
|Spousal Maintenance Received |$ |Disability Payments |$ |
|Pension Payments |$ |Annuity Payments |$ |
|Workers’ Compensation |$ |Self-Employment |$ |
|Unemployment Benefits |$ |Other source of income________________ |$ |
|Total monthly income received: |$ |
OPPOSING PARTY’S INCOME:
|Monthly Income Received |Amount |Monthly Income Received |Amount |
|Salary and Wages (before deductions) |$ |Child’s Derivative Social Security or Veterans’ Benefits |$ |
|Commissions |$ |Military and Naval Retirement |$ |
|Spousal Maintenance Received |$ |Disability Payments |$ |
|Pension Payments |$ |Annuity Payments |$ |
|Workers’ Compensation |$ |Self-Employment |$ |
|Unemployment Benefits |$ |Other source of income________________ |$ |
|Total monthly income received: |$ |
• Total monthly health care insurance costs for the child/ren that you have with the other party: $______________
• Total monthly child care expenses for the child/ren that you have with the other party: $______
Comments or things you would like us to know about the other parties’ income:_____________
_____________________________________________________________________________
If there is an existing order for child support, please bring a copy of it with you to the mediation.
ASSETS
Real Property: (If neither you nor your spouse own real property, check here ). Otherwise, complete the requested information for all real property (including mobile homes and undeveloped land) in which either you or your spouse have any ownership interest.
| |Homestead |Other ________ |
|Residential address (attach copy of legal description)| | |
|Date acquired | | |
|In whose name | | |
|Purchase price | | |
|Mortgage holder (bank) | | |
|Balance on mortgage | | |
|Monthly mortgage payment | | |
|Present fair market value | | |
|Tax assessor’s valuation | | |
|Real estate taxes (yearly) | | |
|Insurance premiums (yearly) | | |
|Does mortgage payment include taxes/insurance ? | | |
|Improvements made to property during marriage | | |
|Is there a non-marital claim regarding any real | | |
|property? | | |
Bank Accounts/Stocks & Bonds/Pension/Life Insurance:
|Type |Institution Name/Address |Account Number(s) |Balance |Name(s) On Account |
|Checking | | | | |
| | | | | |
|Savings | | | | |
| | | | | |
|Certificates of Deposit| | | | |
|Stocks/bonds | | | | |
|Pensions/401k | | | | |
| | | | | |
|Other | | | | |
Personal Property: Please list personal property under the appropriate category and provide details requested. If you have already divided your personal property or do not wish to discuss personal property issues during the mediation, check here and skip to page 8.
|Description |Purchase Price |Present Value |Balance Owing |In Whose Name? |Who has? |
|(include make/model/year) | | | | | |
|Automobiles | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|Boats, motors, campers, snowmobiles, trailers, etc. | | | | | |
| | | | | | |
| | | | | | |
|Electronic equipment (computers, stereos, etc.) | | | | | |
| | | | | | |
| | | | | | |
|Household furnishings/appliances | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|Jewelry and tools | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|Other | | | | | |
| | | | | | |
| | | | | | |
Describe any agreement you and your spouse have reached regarding the allocation of real and/or personal property:________________________________________________________
____________________________________________________________________________
Describe any pre-marital contributions made by either you or your spouse towards the purchase of any assets (real property and personal property):___________________________________
____________________________________________________________________________
____________________________________________________________________________
Tax Refunds: Do you or your spouse have any State or Federal tax refunds coming to you? (yes/no) circle one. If so, give details:______________________________________________
Personal Injury/Workers’ Compensation Claims: Describe any personal injury or workers’ compensation claims you or your spouse have had during the course of the marriage:_________
_____________________________________________________________________________
Inheritances: Describe any inheritances you or your spouse have received during the course of the marriage or expect to receive within the next year:__________________________________
_____________________________________________________________________________
Other Receivables: Describe the circumstances of any other money owed to you or your spouse:
______________________________________________________________________________
List the name and cash value of any life insurance policies on you or your spouse: _______
______________________________________________________________________________
Comments or things you would like us to know about your (or your spouse’s income):________
_____________________________________________________________________________
DEBTS
|Creditor |Balance Due |Monthly Payment |Reason Debt Incurred |Person Incurring Debt |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
Do you plan or want to file bankruptcy on any of the debts listed above?:_______________
If so, have you discussed this plan with your spouse?:________________________________
MONTHLY LIVING EXPENSES
|TYPE OF EXPENSE |YOU |YOUR SPOUSE |CHILD(REN) |
|(PER MONTH) | | |if not living with you or |
| | | |spouse |
|Housing | | | |
|Rent | | | |
|Mortgage payment | | | |
|Contract for deed payment | | | |
|Homeowner’s/renter insurance | | | |
|Utilities | | | |
|Heat | | | |
|Water/sewer | | | |
|Electricity | | | |
|Gas | | | |
|Telephone | | | |
|Refuse disposal | | | |
|Cable TV | | | |
|Home maintenance | | | |
|Housecleaning | | | |
|Household repairs | | | |
|Yard and landscaping expenses | | | |
|Snow removal | | | |
|Transportation | | | |
|Car payment | | | |
|Repairs and maintenance | | | |
|License | | | |
|Insurance | | | |
|Bus/cab fare | | | |
|Clothing/Grooming | | | |
|Clothing purchases | | | |
|Shoes | | | |
|Laundry and drycleaning | | | |
|Haircuts/nail care | | | |
|Food | | | |
|Groceries | | | |
|Dining out | | | |
|Liquor | | | |
|Medical and dental | | | |
|Insurance premiums | | | |
|Unreimbursed medical expenses | | | |
|Unreimbursed optical expenses | | | |
|Unreimbursed dental expenses | | | |
|Educational expenses | | | |
|Tuition, room and board | | | |
|Books and supplies | | | |
|School lunches | | | |
|School activities | | | |
| | | | |
|Childcare | | | |
|Daycare expenses | | | |
|Babysitting expenses | | | |
|Diapers | | | |
|Insurance | | | |
|Life insurance | | | |
|Disability insurance | | | |
|Other insurance:______________ | | | |
|Charitable contributions | | | |
|Church | | | |
|Other:_________________ | | | |
|Other: | | | |
|Entertainment | | | |
|Gifts | | | |
|Hobbies | | | |
|Memberships | | | |
|Pets | | | |
|Postage | | | |
|Travel/vacation | | | |
|Magazine subscriptions | | | |
|Savings | | | |
|Pension | | | |
AGREEMENTS
Describe any agreements that you and your spouse have reached regarding any of the issues in your divorce? (Example: we have agreed that he will keep the house, etc.)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ISSUES
What brings you to the mediation process? What issues would you like to discuss and try to resolve during mediation?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
OTHER
Is there any response(s) in this form that you do not want your spouse to know about? If so, please clearly mark that response/those responses with the words “DO NOT SHARE.”
Are you willing to participate in mediation of this matter willingly and in good faith?_________
Dated:_______________ Signed:_____________________________________________
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FAMILY LAW MEDIATION QUESTIONNAIRE
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