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State of Minnesota
District Court
County of Judicial District:
Court File Number:
Assigned Judge:
Case Type: Dissolution with out Children
In Re the Marriage of:
Name of Petitioner (first, middle, last) Stipulated Findings of Fact,
Conclusions of Law, Order for Judgment, Judgment and Decree
and (Gen. R. Prac. Rule 308.04)
Name of Respondent (first, middle, last)
---------------------------------------------------------------------------------------------------------------------
A. This proceeding for dissolution of marriage came before the undersigned judge of dist rict court
on (date) at
(location) in the State of Minnesota. Petitioner did did not appear. Respondent did
did not appear. appeared as attorney
for .
B. Petitioner is NOT represented by an attorney OR
Petitioner
is represented by the following attorney:
C. Respondent is NOT represented by an attorney OR
Respondent
is represented by the following attorney:
D . Service of the Summons and Petition for Dissolution of Marriage :
Respondent was personally served on _____________________________, __________, OR
Respondent signed an Admission of Service on ______________________ , _________, OR
Respondent was served by alternate means as ordered by the court as follows:
By mailing the Summons and Petition to Respondent at the address(es) stated in the
Order for S ervice by Alternate Means on this date:
By publication of the Summons in _______________________________________
newspaper for 3 consecutive weeks, once each week, on the following 3 dates:
E. Petitioner was served with an Answer and Counter-Petition: YES NO
If YES, Petitioner was served with the Answer and Counter-Petition on
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Month Day Year
F. Petitioner and Respondent have reached an agreement for marital termination resolving all
issues in this case. Petitioner prepared the Stipulated Findings of Fact, Conclusions of Law,
Order for Judgment and Judgment and Decree and inc orporated the stipulated facts and terms
of the parties’ agreement. Respondent and Petitioner have s igned an Acknowledgement
regarding this a greement, which is included in this document.
Findings of Fact
1. Information about Petitioner
Full Name:
First Middle Last
Address where you live:
Street Address Apt. No.
City County State Zip Code
Mailing address :
Same as above address OR
Street Address Apt. No.
City County State Zip Code
Date of Birth: ________________________ Month Day Year
List all of Petitioner’s former or other names or write “None”:
First Middle Last
First Middle Last
Petitioner’s social security number is listed on Confidential Form 11.1 and submitt ed along
with the Petition.
2. Information about Respondent
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Full Name:
First Middle Last
Address where Respondent lives
Street Address Apt. No.
City County State Zip Code
Mailing address :
Same as above address OR
Street Address Apt. No.
City County State Zip Code
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 _____________________, County of _______________________________, State
of __________________________, Country of .
4. 180 Day Requirement
Petitioner has been living in Minnesota for the past six (6) months.
YES NO
Respondent has been living in Minnesota for the past six (6) months.
YES NO
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Petitioner and Respondent were married in Minnesota, but neither Petitioner nor Respondent
reside in Minnesota, nor reside in a jurisdiction that will allow an action for diss olution
because of the sex or sexual orientation of the Petitioner and Respondent.
YES NO
5. Armed Forces
Is Petitioner an active duty member of the armed forces .
YES NO
If YES , has Petitioner been stationed in Minnesota for the past six (6) months?
YES NO
Is Respondent an active duty member of the armed forces.
YES NO
If YES , has Respondent been stationed in Minnesota for the past (6) months?
YES NO
6. Marriage Cannot be Saved
There has been an irretrievable breakdown of the marriage relationship and t he marriage
between Petitioner and Respondent cannot be saved.
7. Physical Living Situation
The Petitioner and Respondent live together at this time
YES NO
If NO , the date of separation was: .
Month Day Year
If YES , Petitioner and Respondent are living together because:
8. Other Proceedings
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A
separate court case for marriage dissolution, legal separation, or annulment has already
been started by Petitioner or Respondent in Minnesot a 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 or
9. Protection or Harassment Order
An Order for Protection or a Harassment/Restraining Order is in effect regarding Petitioner
and Respondent?
YES NO If YES: The Order protects: Petitioner
Respondent and the Order was filed in
County in State on date, and the
Court file number is .
10. Children
“ Minor” children are under age 18, or under age 20 but still in high school.
a. Do Petitioner and Respondent have minor children together?
YES NO
b. Do Petitioner and Respondent have any adult dependent children who are not able to
support themselves because of a physical or mental condition?
YES NO
c. Has either Petitioner or Respondent given birth during the marriage to a child who is not
a child of the other spouse?
YES NO
If you answered NO to c , skip to d. If YES , continue below:
i. Fill in the information for all children born during the marriage who are not biological
children of both spouses.
Full Name of Child Date of Birth Age Which Party is Birth Parent?
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ii. Is there a Court Order naming someone other than the spouse as the father of the
child(ren) listed at i?
YES NO If YES, fill in:
Full Name of Child Date of Court Order County/State of Order Court Case No.
iii. Have the spouse and biological Father signed a Minnesota Recognition of Parentage
(ROP) for any of the children listed in (i) above?
YES NO
If YES , state the full name of the child: _______________
and submit a certified copy of the Recognition of Parentage , if not submitted with
the Petition .
iv. Has a “Husband’s Non-Paternity Statement ” for any of the children listed at (i) above
been signed ?
YES NO
If YES , state the name of the child:
and submit a certified copy of the “Husband ’s Non -Paternity Statement ” if not
submitted with the Petition.
( For eac h minor child listed at c.(i.) there should be a paternity court order OR the
Recognition of Parentage and No n-Paternity Statement to use this Dis solution Without
Children form.)
d. N either spouse is pregnant
YES NO (If either spouse is pregnant use Marriage
Dissolution With Children form.)
11. Public Assistance /Medical Assistance
Note: If either party is receiving public assistance from the State of Minnesota or appl ies for it after
this proceeding is started, the Petitioner should give notice of this marr iage dissolution action to
the Public Authority office for the county p aying the assistance.
a. Petitioner receives public assistance from the State of Minnesota:
YES NO
If YES, the assistance is from _______________________County. (Check all that apply):
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MFIP Tribal TANF General Assistance Child Care Assistance
Minnesota Care Medical Assistance
b. Respondent receives public assistance from the State of Minnesota:
YES NO
If YES, the assistance is from _______________________County. (Check all that apply):
MFIP Tribal TANF General Assistance Child Care Assistance
Minnesota Care Medical Assistance
12. 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. Petitioner receives Supplemental Security Income:
NO YES in the amount of
$____________ per month.
b. Respondent receives Supplemental Security Income:
NO YES in the amount of
$____________ per month.
13. Petitioner’s Employment
a. Petitioner is employed .
YES NO
b. Petitioner is Self -Employed .
YES NO
c . Name and address of Petitioner’s employer. (If Petitioner has more tha n one job, list the
Name and Address of each employer.)
_____________________________________________________________________
Name of Petitioner’s Employer (If Self -Employed, list name and business address)
_____________________________________________________________________
Employer’s Street Address
_____________________________________________________________________
City State Zip Code
Name of Petitioner’s Employer (If Self-Employed, list name and business address)
_____________________________________________________________________
Employer’s Street Address
_____________________________________________________________________
City State Zip Code
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14.
Petitioner’s Gross Income
The Income questions ask for monthly income. If you are paid weekly, multiply your weekly
income by 4.33 to get monthly income. If you are paid every two weeks, multiply by 2.17 to get
monthly income. If you are paid twice a month, multiply by 2.
Source of Income Amount per month (or zero) before taxes and deductions
Self Employment Income $________________per month
Self Employment income means gross receipts minus cost of goods sold minus ordinary and
necessary business expenses. Use monthly average.
Income from all j obs $________________ per month
Commissions f rom all jobs $________________ per month
Unemployment benefits $________________ per month
Social Security Retirement, Survivors or
Disability Income $________________ per month
In vestments or 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 you receive $________________ per month
Other ____________________ $________________ per month Identify Source
Total gross income $ _______________ per month
Petitioner receive child support payments.
YES NO
If YES, Petitioner receives child support payments from
____________________________(name(s) of payor(s)) in the total amount of
$_________________per month.
15. Respondent’s Employment
a. Respondent is employed.
YES NO
b. Respondent is Self -Employed .
YES NO
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Name and address of Respondent’s employer. (If Respondent has more than one job,
list the Name and Address of each employer.)
_____________________________________________________________________
Name of Respondent’s Employer (If Self -Employed list name and business address)
_____________________________________________________________________
Employer’s Street Address
_____________________________________________________________________
City State Zip Code
____________________________________________________________________
Name of Respondent’s Employer (If Self -Employed list name and business address)
_____________________________________________________________________
Employer’s Street Address
City State Zip Code
16. Respondent’s Gross Income
The Income questions ask for monthly income. If Respondent is paid weekly, multiply weekly
income by 4.33 to get monthly income. If Respondent is paid every two weeks, multiply by 2.17
to get monthly income. If Respondent is paid twice a month, multiply by 2.
Source of Inc Amount per month (o r zero) before taxes and deductions
Self Employment Income $________________ per month
Self Employment income means gross receipts minus cost of goods sold minus ordinary and
necessary
business expenses. Use monthly average.
Income from all j obs $________________ per month
Com missions from all jobs $________________ per month
Unemployment benefits $________________ per month
Social Security (SSDI or RSDI) $________________ per month
In vestments or Rental Income $________________ per month
Annuity payments $________________ per month
Pension or Disability from work or military $________________ per month
Worker’s Compensation $________________ per month
Court-ordered spou sal maintenance you receive $________________ per month
Other ____________________ $________________ per month Identify Source
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Total gross income $ _______________ per month
Does Respondent receive child support payments?
YES NO
If YES, Respondent receives child support payments from
____________________________(name(s) of payor(s)) in the total amount of
$_________________per month.
17. Health Care Coverage
a. Petitioner ha s insurance coverage through his/her employment .
Medical:
YES NO Dental: YES NO
If YES, this medical insurance covers:
Petitioner Respondent and this dental
insurance covers:
Petitioner Respondent
b. Respondent has insurance coverage through his/her employment .
Medical:
YES NO Dental: YES NO
If YES, this medical insurance covers:
Petitioner Respondent and this dental
insurance covers:
Petitioner Respondent
c. P etitioner receive s Medical Assistance or Minnesota Care through the State of
Minnesota.
YES NO
d. R espondent receive s Medical Assistance or Minnesota Care through the State of
Minnesota.
YES NO
18. Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.
Check only one box:
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Petitioner and Respondent do not need spousal maintenance at this time, or in the
future. Both parties agree that each party is fully capable of self -support and is not
dependent upon the other for ad ditional support in the form of spousal maintenance. Each
party has made a full and fair disclosure of all income and assets and liabilities t hat each is
responsible for, and agrees that this waiver is reasonable. The waiver is fair and equitable
and is supported by the above consideration and was signed by both parties after full
financial disclosure to each other.
Petitioner or Respondent may need spousal maintenance in the future. The court
should reserve maintenance to allow either party to ask for spousal maintenance in the
future because:
(explain why you want to do this)
Petitioner needs spousal maintenance from Respondent now. Petitioner is __________
years of age, Petitioner and Respondent have been married for _________ years. Petitioner
has the 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:
Respondent has the ability to pay Petitioner $_____________per month for spousal
maintenance.
Respondent needs spousal maintenance from Petitioner now. Respondent is
__________ years of age, Petitioner and Respondent have been married for _________
years. R espondent has the following education:
. Respondent’s gross monthly income totals
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$______________. Respondent’s monthly expenses total $________________, and
Respondent is not able to maintain the standard of living established during the marria
ge
because:
Petitioner has the ability to pay Respondent $_____________per month for spousal
maintenance.
19. Vehicles
Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles
etc. owned by Petitioner and Respondent together or separately, including vehicles purchased after
separation:
Petitioner own s a vehicle .
YES NO
Respondent owns a vehicle.
YES NO
List all vehicles owned by Petitioner and Respondent together or separately:
Type of
Vehicle (car,
boat, truck etc.)
Year/Make/
Model
Name(s) on
Title
Value Balance Owed Monthly
Payment
$ $ $
$ $ $
$ $ $
$ $ $
20. Marital Property
Marital property means almost anything that you or your spouse now own that was r eceived
or bought during the marriage, even during the times you were separated. Marital Property
includes household goods, furniture, jewelry, boats, real estate and other things. Marital
property does not include a gift or inheritance received by one spouse alone.
T he marital property been divided between Petitioner and Respondent to their satisfaction.
YES NO
If NO , Petitioner requests the following marital property:
________________________________________________________________________
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If NO , Respondent requests the followin g marital property:
__________________________________________________________________
21. 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, beque st, devise, or
inheritance, to you or your spouse alone ; (3) anything that you or your spouse got in t rade
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 valuati on date
set by the court; or (6) anything defined as non -marital property by a valid antenuptial
contract.
a. Petitioner has non-marital property .
YES NO
If YES, list Petitioner’s non -marital property:
b. Respondent has non- marital property. YES NO
If YES, list Respondent’s non- marital property:
_____________________________________________________________________
22. Cash & Accounts – Not including Pension and Emplo yer-Funded Retirement
Accounts
Petitioner has money in banks, savings, cash or investments.
YES NO
Respondent has money in banks, savings, cash or investments.
YES NO
If YES,
a. List all accounts owned by you alone, your spouse alone, or owned by both of you jointly
including those opened after separation. “Type of account” means checking, savings,
money market accounts, certificates of deposit, stocks, bonds, stock options, mutual funds ,
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savings bonds, and Treasury Bills, etc. Use Confidential Information Form 11.1 (C
ON111)
to list Financial Institution name, account holder name(s), and account numbers.
Do not include Pension or Employer-Funded Retirement Accounts, which are listed at #26.
Financial
Institution
Type of Account Amount Belongs to:
(name on account)
$
$
$
$
$
$
b. List cash not listed at a.:
Petitioner has cash in the amount of $ .
Respondent has cash in the amount of $
23. B usiness Interest
Petitioner has an interest in a business.
YES NO
Respondent has an interest in a business.
YES NO
If YES, the name of the business is ____________________________, the address is ________________________________________________________________________
and the value is $________________. I arrived at this value as follows:
24. Manufactured Home
Petitioner own s a manufactured home.
YES NO
Respondent owns a manufactured home .
YE S NO
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If either Petitioner or Respondent own a manufactured home, together or separat
ely,
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 money 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 25.
25. Real Property - Land, Buildings, Contracts for Deed
All real property now owned by Petitioner or Respondent together or separate ly must be listed.
Include real property acquired before the marriage, during the marriage, an d after separation.
a. Petitioner and Respondent jointly own real property. YES NO
b. Petitioner own s real property solely in his/her own name or with someone other than
Respondent.
YES NO
c. Respondent own s real property solely in his/her own name or with someone other than
Petitioner .
YES NO
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d.
How many properties are owned by you and your spouse in total?
None One
Two
Three _______
If you or your spouse own real property, separately or together, complete the following
information about the property. If there is more than one piece of real property , photocopy
and complete a Real Property Informatio n page for each piece of property. Stapl e the
ad ditional sheets to the Stipulated Findings of Fact and label each sheet "Attachment to
Stipulated Findings of Fact of ____________________(your names )"
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 tax statement legal description. If the legal
description is long, you may use an attachment. Type or print neatly.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
3. Street Address of the 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.
1 st
Mortgage: Amount currently owed $ and name of lender
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2
nd
Mort gage: Amount currently owed $ and name of lender
Other mortgages or loans:
6. Current Market Valu e of this property:$
How did you arrive at this value?
7. This property is the homestead: _______Yes _________No 26. Retirement Plans
a. Petitioner has a retirement account . (IRA, 401(k), 403(b) or other)
YES NO If YES: The name of the Financial Institution, account holder name(s),
and account number is listed on Confidential Information Form 11.1 (CON111). The
current balance is: $
b. Petitioner , or Petitioner’s past or present employer, union, or other group, paid money
into a pension, profit sharing, or other retirement plan for Petitioner.
YES NO If YES:
i. The name of the plan is:
ii. The employer, union or group providing the plan is:
iii. The date Petitioner began working at the job or joined the union or group plan is:
iv. The type of plan is: (e.g. defined benefit, defined contribution)
v. The present value of the pension or plan is:
c. Respondent has a retireme nt account. (IRA, 401(k), 403(b) or other)
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YES NO If YES: The name of the Financial Institution, account holder name(s),
and account number is listed on Confidential Information Form 11.1 (CON111). The
current balance is: .
d. 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 If YES , and it is a Pension, Profit -Sharing, or other Retirement
Plan:
i. The name of the plan is:
ii. The employer, union or group providing the plan is:
iii. The date Respondent began working at the job or joined the union or group plan is:
iv. The type of plan is: (e.g. defined benefit, defined contribution)
v. The present value of th e pension or plan is:
27. Debts
Petitioner has debts.
YES NO
Respondent has debt s.
YES NO
If YES, list debts in your name, your spouse’s name and in both names jointly. Include
unpaid debts from before the marriage date, during the marriage, and after sepa ration.
Fill in all information completely and attach another 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
$ $
$ $
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$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Total Debt $ $
28. Name Change
a. Neither person wants to change his/her name.
b. Petitioner Respondent wants to change his/her name to: ( full name, not
initials )
first middle last
This name change request is made with no intent to defraud or mislead anyone:
True False.
The person requesting the name change has been convicted of a felony :
YES NO
If YES:
i. Notice of this request for name change has been given to the proper authority a s
required by Minn. Stat. § 259.13. (IMPORTANT NOTICE: If you are a convicted felon
and you request a name change without following the requirements of Minn. Stat . § 259.13,
using the new last name after your divorce is a gross misdemeanor.)
ii. An Affidavit of Service of the Notice marked Exhibit “A” has been submitted along
with this Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment
and Decree.
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29.
Other Findings
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
BASED UPON THE ABOVE INFORMATION, the parties agree that the Court shall
make the following:
CONCLUSIONS OF LAW
1. The bonds of matrimony between Petitioner and Respondent are dissolved, so they are
single and not married.
2. Health Care Coverage for the Parties
a. Each party to provide for his or her own medical dental insurance.
b. ____________________________(full name) shall provide medical
den tal insurance for
(full name)
c. Allowing____________________________(full name), at his/her own expense, to
continue the dependent coverage available under the other party’s insurance plan,
pursuant to federal and state statutes.
d. Reserving the issue of medical and dental insurance for the parties.
3. Spousal Maintenance
a. Neither party is awarded spousal maintenance. Petitioner and Respondent have
waived any claim s to spousal maintenance for the p ast, present, or future and expressly
waive all rights to modify their waiver s of maintenance. This court is divested of
jurisdiction to award or modify maintenance in the future pursuant to Karon v. Karon, 435
N.W.2d 501 (Minn. 1989).
Consideration for this agreement is: (check all that apply)
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the parties’ mutual waiver s of maintenance
the property settlement
the parties’ respective incomes and ability to earn income
other:
The Court has reviewed this agreement and finds it to be fair and equitable under all of the
circumstances, and supported by sufficient consideration including the parties’ mutual
waivers, incomes per year and the property division. Full disclosure of each party’s financial
circumstances has occurred.
b. Maintenance is reserved because:
Either party can ask the court to order the payment of spousal maintenance in the
future by filing a Motion stating a cha nge in circumstances.
c. Petitioner Respondent shall pay permanent spousal maintenance to the other
party in the amount of $ _________ per month starting on
(date ):________________________. Any past due amounts are still owed.
d. Petitioner Respondent shall pay temporary spousal maintenance to the other
party in the amount of $ _________ per month starting on (date):
__________________________ and ending:
Any past due amounts a re still owed.
The monthly amount of permanent or temporary spousal maintenance shall be:
subject to income withholding from the payor’s income, regardless of source, by his or
her e mployer, trustee, or other payor of funds and mailed to: Minnesota Child Support
Payment Center, P.O. Box 64326, St. Paul, MN 55164 -0326. If the person paying spousal
support is self -employed, send payments to Minnesota Child Support Payment Center, P.O.
Box 64306, St. Paul, MN 55164 -0306. To start income withholding, Petitioner or
Respondent must apply for income withholding at the Child Support Office in their
county. Until income withholding starts, the person owing maintenance shall pay the
amount directly to the spouse receiving it.
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OR
Maintenance shall be paid directly by the spouse owing the maintenance to the spous e
receiving it, payable on the ____________________day of each month.
4. Vehicles
Awarding the vehicles as follows and ordering the party receiving the vehicle s to pay for
any loans or insurance for such vehicle:
Year / Make / Model Awarded to:
5. Marital Property
The parties’ marital property, household goods, furniture and furnishings are awa rded:
a. As currently divided OR
b. As follows ( add pages if necessary):
To Petitioner:
To Respondent:
6. Non-Marital Property
The parties’ non- marital property is awarded:
a. As currently divided OR
b. As follows (add pages if necessary):
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To Petitioner:
To Respondent:
7. Cash and Accounts
a. Awarding the sa vings and investments as follows:
Institution Type of Account Amount Awarded to
$
$
$
$
$
$
b.
Awarding any cash not included in a. above to the party who currently has the cas h
OR
Awarding the cash as foll ows:
8. Business
None OR
Awarding the parties’ business as follows:
9. Manufactured Hom e
None OR
Awarding the manufactured home located at :
street address
city state
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to
Petitioner Respondent. The debt on the manufactured home owed to:
shall be paid by Petitioner Respondent.
10. Real Property
None OR
Awarding solely to Petitioner Respondent all righ t, title, and interest of
the parties 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:
1 st
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: (describe the request fully)
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11.
Additional Real Property
None OR
Awarding solely to Petitioner Respondent all righ t, title, and interest of the
parties 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:
1 st
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 o f $
Other request regarding the property: (describe the request fully)
12. Retirement Funds
a. Awarding Petitioner’s pension, profit sharing, retirement plan, I.R.A., or 401(k) or ot her
retirement fund as follows:
Petitioner has no retirement funds OR
100% to Petitioner OR
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Dividing Petitioner’s retirement benefits fairly and equitably between the p arties as
follows:
b. Awarding Respondent’s pension, profit sharing, retirement plan, I.R.A. , or 401( k) or
other retirement fund as follows:
Respondent has no retirement funds OR
100% to Respondent OR
Dividing Respondent’s retirement benefits fairly and equitably between the par ties as
follows:
13. Debts
a. Dividing the debts as follows and ordering each party to hold the other harmless
from any responsibility for the debts so divided. In clude all debts listed at #27
above.
Debt Owed To: To Be Paid By:
b. Ordering that e ach 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 se parately incurred debts.
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14.
Name Change
Neither party is requesting a name change.
OR
Changing Petitioner’s name to:
First Middle Last
Changing Respondent’s name to:
First Middle Last
15. Other :
16. Each party shall execute any and all documents necessary to trans fer real and personal
property as awarded herein without further order of the Court. Should e ither party fail to
execute the necessary documents, a certified copy of the Judgment and Dec ree shall operate
to transfer title as awarded .
17. Petitioner and Respondent agree that after a Judgment and Decree has been entered her ein,
Petitioner may have a third party, age 18 or older, serve the Judgment and Decree upon
Respondent by mailing it to Respondent’s last known address by first class mai l, postage
prepaid. The parties agree that service by mail instead of personal service shall constitute
proper service of the Judgment and Decree for all purposes. Petitioner is responsible for
fil ing an Affidavit of Service of the Judgment and Decree in the court file.
NOTICE: APPENDIX A SHALL BE INCORPORATED AND MADE A PART OF THE
JUDGMENT AND DECREE. Appendix A contains provisions regarding Payments to Public
Agency, Minnesota Statutes § 518A.50; Depriving Another of Custodial or Parental Right s-- A
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Felony, Minnesota Statutes § 609.26; Rules of Support, Maintenance, Parenting Time; Pare
ntal
Rights from Minnesota Statutes § 518.17, subdivision 3; Wage and Income Deduction of Support
and Maintenance, Minnesota Statutes § 518A.53; Change of Address or Residence; Cost of Living
I ncrease of Support and Maintenance pursuant to Minnesota Statutes § 518A.75; Judgments for
U npaid Support pursuant to Minnesota Statutes § 548.091; Judgments for Unpaid Maintenance
pursuant to Minnesota Statutes §548.091; Medical Insurance and Expenses pursuant to Minnesota
Statutes § 518A.41; and Minnesota Statutes § 259.115 regarding criminal penalties for fai lure to
comply wit h felon name change law.
ACKNOWLEDGEMENT
The undersigned parties affirm to the Court that the foregoing Conclusions of Law
incorporate the parties’ complete and full agreement for marital termination to re solve all issues
in this dissolution case, and upon approval and entry by the court, shall constitute the judgment
and decree for marriage dissolution for all purposes. Furthermore, the parties assert that the facts
stated in the Findings of Fact are true and accurate, that each party has fully disclos ed the nature
and extent of his or her property, debts, and income, and that this agreement is based upon that full
and fair disclosure. The parties ask the Court to enter judgment in strict conformit y with the
foregoing and, so long as the Court does so, the parties agree that this ma tter may proceed as by
default. If the Court intends to deviate at all from the terms of the foregoing, each pa rty shall be
notified and given the opportunity to present all arguments concerning all issue s in the dissolution
case.
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STATE OF MINNESOTA
) STATE OF MINNESOTA )
) SS ) SS
COUNTY OF ) COUNTY OF )
(County where document is signed) (County where document is signed)
I declare under penalty of perjury that everything I have stated in this do cument is true and correct.
Minn. Stat. § 358.116.
DATED: ____________________________ DATED:
____________________________________
Signature of Petitioner Signature of Respondent
Petitioner Respondent
is not represented by an attorney is not represented by an attorney
(Sign Petitioner’s Waiver of Counsel) (Sign Respondent’s Waiver of Counsel )
is represented by the following attorney: is represented by the fol lowing attorney:
Attorney’s Name: Attorney’s Name:
Attorney’s ID #: Attorney’s ID #:
Telephone: ( ) Telephone: ( )
Attorney’s Address Attorney’s Address
City, State, Zip _________________________ City, State, Zip
E-mail address ______________________________ E-mail address
By ________________________________________ By
Attorney for Petitioner Attorney for Respondent
ORDER FOR JUDGMENT
LET JUDGMENT BE ENTERED IMMEDIATELY.
The foregoing facts were found by me after due BY THE COURT
hearing and the Order thereon is recommended.
____________________________________
District Court Referee Judge of District Court
Dated: Dated:
JUDGMENT
I certify the above Conclusions of Law are the Judgment of the Court and Judgment is hereby
entered .
___________________________________________ Court Administrator
Deputy
Dated:
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PETITIONER’S WAIVER OF COUNSEL
I, , know I have the right to be represented by a
lawyer of my choice. I hereby expressly waive that right and I freely an d voluntarily sign the
foregoing stipulation to terminate my marriage and resolve all issues in this marr iage dissolution
case. I understand that an attorney would be helpful in determining the issues contained in t he
foregoing stipulation; however, I specifically decline to retain independent couns el.
__________________________ __________________________________________ Date Signature of Petitioner
RESPONDENT’S WAIVER OF COUNSEL
I, __________________________________ declare as follows:
1. I know I have the right to be represented by an attorney of my choice. I hereby
expressly waive that right and I freely and voluntarily sign the foregoing stipulation to terminate
my marriage and resolve all issues in this marriage dissolution case.
2. I understand that an attorney would be helpful in determining issues contained in
the foregoing stipulation; however, I specifically decline to retain independent counsel.
3. I hereby expressly waive any right to contest the agreements set forth in t he
foregoing stipulation and I waive the thirty (30) days period to answer.
4. My spouse may proceed to judgment pursuant to the terms of said stipulation as if
by default, and without further notice to me.
__________________________ ____________________________________ Date Signature of Respondent
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APPENDIX A
NOTICE IS HEREBY GIVEN TO THE PARTIES:
I. PAYMENTS TO PUBLIC AGENCY. According to Minnesota Statutes, section 518A.50, payments ordered for
maintenance and support must be paid to the Minnesota child support payment center as long as the person entitled to receive
the payments is receiving or has applied for public assistance or has applied for supp ort and maintenance collection services.
Parents mail payments to: P.O. Box 64326, St. Paul, MN 55164 -0326. Employers mail payments to: P.O. Box 643 06, St. Paul,
MN 55164.
II. DEPRIVING ANOTHER OF CUSTODIAL OR PARENTAL RIGHTS -- A FELONY. A person may be
charged with a f elony who conceals a minor child or takes, obtains, retains, or fails to return a minor child from or to the child's
parent (or person with custodial or parenting time rights), according to Minnesota St atutes, section 609.26. A copy of that
section is ava ilable from any court administrator.
III. NONSUPPORT OF A SPOUSE OR CHILD – CRIMINAL PENALTIES. A person who fails to pay court -
ordered child support or maintenance may be charged with a crime, which may include m isdemeanor, gross misdemeanor, or
felon y charges, according to Minnesota Statutes, section 609.375. A copy of that section is av ailable from any district court
clerk.
IV. RULES OF SUPPORT, MAINTENANCE, PARENTING TIME.
A. Payment of support or spousal maintenance is to be as ordered, and the giving of gifts or making purchases of food,
clothing, and the like will not fulfill the obligation.
B. Payment of support must be made as it becomes due, and failure to secure or denial of parenting time is NOT an
excuse for nonpayment, but the aggrieved party must seek relief through a proper moti on filed with the court.
C. Nonpayment of support is not grounds to deny parenting time. The party entitled to r eceive support may apply
for support and collection services, file a contempt motion, or obtain a judgment as provided in Minnesota
Statutes, section 548.091.
D. The payment of support or spousal maintenance takes priority over payment of debts and other obl igations.
E. A party who accepts additional obligations of support does so with the full knowledge of the party's prior obligation
under this proceeding.
F. Child support or maintenance is based on annual income, and it is the responsibility of a person w ith seasonal
employment to budget income so that payments are made throughout the year as ord ered.
G. A Parental Guide to Making Child -Focused Parenting -Time Decisions is available from any court administrator.
H. The nonpayment of support may be enforced through the denial of student grants; interception of state and federal tax
refunds; suspension of driver’s, recreational, and occupational licenses; refe rral to the department of revenue or private
collection agencies; seizure of assets, including bank accounts and other assets held by financial institutions; reporting
to credit bureaus; interest charging, income withholding, and contempt proceedings; and other enforcement methods
allowed by law.
I. The public aut hority may suspend or resume collection of the amount allocated for child care expenses i f the conditions
of Minnesota Statutes, section 518A.40, subdivision 4, are met.
J. The public authority may remove or resume a medical support offset if the condit ions of section 518A.41, subdivision
16 , are met.
K. The public authority may suspend or resume interest charging on child support judgments i f the conditions of section
548.091, subdivision 1a, are met.
V. MODIFYING CHILD SUPPORT. If either the obligor or obligee is laid off from employment or receives a pay
reduction, child support may be modified, increased, or decreased. Any modification wi ll only take effect when it is ordered
by the court, and will only relate back to the time that a motion is filed. Either the obligor or obligee may file a motion to
modify child support, and may request the public agency for help. UNTIL A MOTION IS FI LED, THE CHILD SUPPORT
OBLIGATION WILL CONTINUE AT THE CURRENT LEVEL. THE COURT IS NOT PERMITTED TO REDUCE
SUPPORT RETROACTIVELY.
VI. PARENTAL RIGHTS FROM MINNESOTA STATUTES, SECTION 518.17, SUBDIVI SION 3. UNLESS
OTHERWISE PROVIDED BY THE COURT:
A. Each party has the right of access to, and to receive copies of, school, medical, dental, re ligious training, police reports,
and other important records and information about the minor children. Each party has the r ight of access to information
regarding health or dental insurance available to the minor children. Presen tation of a copy of this order to the
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custodian of a record or other information about the minor children constitutes suffici
ent authorization for the release
of the record or information to the requesting party.
B. Each party has the right to be informed by the other party as to the name and address of the school of attendance of
the minor children. Each party has the right to be informed by school offi cials about the children's welfare, educational
progress and status, and to attend school and parent teacher conferences. The sc hool is not required to hold a separate
conference for each party.
C. Each party has the right to be notified by the other party of an accident or serious illne ss of a minor child, including
the name of the health care provider and the place of treatment.
D. Each party has the right to be notified by the other party if the minor child is the victim of an alleged crime, including
the name of the investigating law enforcement officer or agency. There is no dut y to notify if the party to be notified
is the al leged perpetrator.
E. Each party has the right of reasonable access and telephone contact with the minor child ren.
VII. WAGE AND INCOME DEDUCTION OF SUPPORT AND MAINTENANCE. Child support and / or
spousal maintenance may be withheld from income, with or without notice to the person oblig ated to pay, when the conditions
of Minnesota Statutes, section 518A.53, have been met. A copy of that section is available from any court administrator.
VIII. CHANGE OF ADDRESS OR RESIDENCE. Unless otherwise ordere d, each party shall notify the other
party, the court, and the public authority responsible for collection, if applicabl e, of the following information within ten days
of any change: residential and mailing address, telephone number, driver's lic ense number, social security number, and name,
address, and telephone number of the employer.
IX. COST OF LIVING INCREASE OF SUPPORT AND MAINTENANCE. Basic support and / or spousal
maintenance may be adjusted every two years based upon a change in the cost of li ving (using the U.S. Department of Labor,
Bureau of Labor Statistics, consumer price index Mpls. St. Paul, for all urban consumer s (CPI-U), unless otherwise specified
in this order) when the conditions of Minnesota Statutes, section 518A.75, are met. Cost of living increases are compounded.
A copy of Minnesota Statutes, section 518A.75, and forms necessary to request or contest a cost of living increase are available
from any court administrator.
X . JUDGMENTS FOR UNPAID SUPPORT; INTEREST. According to Minnesota Statutes, section 548.091:
A. If a person fails to make a child support payment, the payment owed becomes a judgment aga inst the person
responsible to make the payment by operation of law on or after the date the payment is due, a nd the person entitled
to receive the payment or the public agency may obtain entry and docke ting of the judgment without notice to the
person responsible to make the payment.
B. Interest begins accruing on a payment or installment of child support whenever the unpa id amount due is greater than
the current support due.
XI. JUDGMENTS FOR UNPAID MAINTENANCE. A judgment for unpaid spousal maintenance may be entered
and docketed when the conditions of Minnesota Statutes, section 548.091, are met. A copy of that s ection is available from
any court administrator.
XII. ATTORNEY FEES AND COLLECTION COSTS FOR ENFORCEMENT OF CHILD SUPPORT. A
judgment for attorney fees and other collection costs incurred in enforcing a chil d support order will be entered against the
person responsible to pay support when the conditions of Minnesota Statutes, section 518A.735, are met. A copy of that
section and forms necessary to request or contest these attorney fees and collection costs ar e available from any court
administrator.
XIII. PARENTING TIME EXPEDITOR PROCESS. On request of either party or on its own motion, the court
may appoint a parenting time expeditor to resolve parenting time dispute s under Minnesota Statutes, section 518.1751. A copy
of that section and a description of the expeditor process is available from any court administrator.
XIV. PARENTING TIME REMEDIES AND PENALTIES. Remedies and penalties for wrongful denial of
parenting time are available under Minnesota Statutes, section 518.175, subdivis ion 6. These include compensatory parenting
time; civil penalties; bond requirements; contempt; and reversal of custody. A copy of that subdivision and forms for
requesting relief are available from any court administrator.
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In addition to the Notices on pages 31 an
d 32, the following NOTICE applies to all orders addressing custody pursuant
to Minn. Stat. § 518.17, subd. 3a.
NOTICE
EACH PARTY IS GRANTED THE FOLLOWING RIGHTS:
1. Right of access to, and to receive copies of, school, medical, dental, religious training, police reports, and other
important records and information about the minor children.
2. Right of access to information regarding health or dental insurance available t o the minor children.
3. Right to be informed by the other party as to the name and address of the school of attendanc e of the minor children.
4. Right to be informed by school officials about the children’s welfare, educational prog ress and status, and to attend
school and parent -teacher conferences. The school is not required to hold a se parate conference for each party, unless
attending the same conference would result in violation of a court order prohibiting contact with a party.
5. Right to be notified by the other party of an accident or serious illness of a minor chil d, including the name of the
health care provider and the place of treatment.
6. Right to be notified by the other party if the minor child is the victim of an alleged c rime, including the name of the
investigating law enforcement officer or agency. There is no duty to notify if the party to be notified is the alleged
perpetrator.
7. Right to reasonable access and telephone or other electronic contact with the minor c hildren.
