Are you living in Hennepin County and need to obtain your ICMC form? The process can feel complicated and daunting.�Fortunately, we’re here to make it easy. In this post, we provide an overview of the Hennepin County ICMC Form and explain the steps you must take to obtain it. We will also offer some helpful tips that may aid you along the way should any bumps appear on the path. Read on to learn more about filing for your ICMC Form in Hennepin County!
| Question | Answer |
|---|---|
| Form Name | Hennepin County Icmc Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | initial case management form, conference court hennepin, county icmc data, hennepin icmc |
STATE OF MINNESOTA |
FOURTH JUDICIAL DISTRICT COURT |
COUNTY OF HENNEPIN |
FAMILY COURT DIVISION |
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PETITIONER’S RESPONDENT’S |
________________________________ |
INITIAL CASE MANAGEMENT |
Petitioner |
CONFERENCE DATA SHEET |
and |
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________________________________ |
Court File No: |
Respondent |
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∙This form must be completed with the best information available at the time of completion and submitted directly to the assigned judicial officer’s chambers by email, mail or fax at least three (3) business days before the Initial Case Management Conference. A copy of the completed form must also be provided to the other party.
∙This form should NOT be filed into the official court file.
∙The information provided will be used solely for the purposes of the Initial Case Management Conference and assessment of fees and is not considered as evidence.
∙Please mail this form to: FJC, Attn. Judge/Referee _____________, 110 S. 4th Street, Minneapolis, MN 55401 or email/FAX directly to the assigned Judicial Officer at least 3 days prior to the Initial Case Management Conference.
I, ______________________________ (print your full name), state that the information contained in this document is true
and correct to the best of my knowledge.
1.BACKGROUND INFORMATION:
a)Your date of birth: ____________________
b)Your current address: _________________________________________________________________________
c)Names of adults that live with you: _______________________________________________________________
d)Do you have any physical or mental health, chemical dependency, or criminal issues that may affect this proceeding?_________________________________________________________________________________
___________________________________________________________________________________________
c)Are you or have you been involved in any other family court cases, including cases involving an Order for
Protection? If yes, please provide the court file numbers:_________________________
___________________________________________________________________________________________
2.INFORMATION REGARDING THE CHILDREN:
a)List the names, birthdates, and ages of the minor joint children of this relationship:
Child’s Name
Child’s Birth Date
Child’s Age
With whom does the child live?
b) List the names, birthdates, and ages of other minor children residing with you:
Child’s Name
Child’s Birth Date
Child’s Age
What is your relationship to the child?
c) |
Do any of the children of this relationship have special needs? |
No If yes, explain: _____________ |
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___________________________________________________________________________________________ |
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d) |
Are there any juvenile court proceedings currently open that affect your children? |
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If yes, what is the court file number? _____________________________________________________________ |
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e)Current parenting time arrangements for the children: ________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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f) Do you have an agreement about parenting issues? If Yes, what is the agreement? _________
___________________________________________________________________________________________
___________________________________________________________________________________________
3.INFORMATION REGARDING FINANCES, ASSETS, DEBT:
a)Your employer and address: ____________________________________________________________________
How long have you been employed? __________________ Your gross monthly income: $__________________
b)Other sources of income: ______________________________________________________________________
c)Your major monthly expenses:
Expense Type |
Cost |
Expense Type |
Cost |
Housing |
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Utilities |
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Food |
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Clothing |
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Transportation |
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Medical Expenses |
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Other Maintenance Obligations |
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Other Child Support Obligations |
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Education Expenses |
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Other |
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Other |
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Total of all major monthly expenses: |
$ |
d)Is there an agreement regarding financial support (spousal maintenance/child support)?
If yes, what is the agreement? __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
e) |
Do you own a home? |
If yes, what is the homestead address:_______________________ |
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___________________________________________________________________________________________ |
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Approximate homestead market value: $______________ Is there a mortgage(s) on the home? |
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If yes, what is/are the balance(s)?________________________________________________________________ |
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f) |
Do you have a retirement plan? |
If yes, it’s approximate value: _______________________ |
g)List all of your other assets valued at over $7,500.00 and their approximate values: ________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
h)List all significant debts and the approximate amounts that you owe: ____________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
i) |
Do you claim that any of these assets or debts are |
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If yes, please identify which |
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assets or debts you claim are |
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___________________________________________________________________________________________ |
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j) |
Is there an agreement regarding |
the division of property? |
No |
If yes, what is the |
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agreement?__________________________________________________________________________________ |
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___________________________________________________________________________________________ |
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___________________________________________________________________________________________ |
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k) |
Are you currently receiving any form of public assistance? |
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(check all that apply) |
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Cash public assistance (MFIP) |
Diversionary Work Program (DWP) |
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Medical Assistance |
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General Assistance (MN) |
Social Security Benefits (SSI) |
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TEFRA |
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Minnesota Care |
Child Care subsidy |
Food Stamps |
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Other ______________ |
5.ATTACH COPIES OF THE FOLLOWING DOCUMENTS TO THIS DATA SHEET. DO NOT SEND ORIGINALS:
a)Attach the five (5) most recent paystubs from your employment.
b)Attach your most recent Federal Tax Return with all attachments, including
c)Attach any unemployment compensation statements, worker’s compensation statements, social security benefits statements, and all other documents evidencing earnings or income received during the last three months.
__________________________________ ___________________ |
______________________ _____________________ |
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Attorney or Pro Se Party Signature |
Date |
Attorney I.D. Number |
Phone number |
__________________________________ _______________________________________ __________________________
Address |
City, State, Zip |
Email Address |
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