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) Findings of Fact, Conclusions
of Law, Order for Judgment,
and Judgment and Decree
Name of Respondent (first, middle, last)
---------------------------------------------------------------------------------------------------------------------
A. This proceeding for dissolution of marriage came before the undersigned judge of district
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 Service by Alternate Means on this date:
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By publication of the Summons in ________________________________ newspaper
for 3 consecutive weeks, once each week, on the following 3 dates:________________,
_______________________, and ________________________.
E. Petitioner was served with an Answer and Counter-Petition : YES NO
If YES, Petitioner was served with the Answer and Counter-Petition on _______________
Month Day Year
F. Respondent did not respond, so Petitioner proceeded by default.
(Note: If the parties reached an agreement, use the Stipulated Findings of Fact, Conclusions
of Law, Order for Judgment, Judgment and Decree. )
Findings of Fact
1. Information about Petitioner
Full Name: _______________________________________________________________
First Middle
Last
Address:
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
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First Middle Last
Petitioner’s social security number is listed on Confidential Form 11.1 and submitted along
with the Petition.
2. Information about Respondent
Full Name:
First Middle Last
Address:
Street Address Apt. No.
City County State Zip
Code
Respondent's address is unknown.
Date of Birth: ________________________
Month Day Year
List all of Respondent’s former or other names or write “None”:
First Middle Last
First Middle Last
Respondent’s social security number is listed on Confidential Form 11.1 and submitted
along with the Petition.
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 UNKNOWN
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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
dissolution because of the sex or sexual orientation of the Petitioner and Respondent.
YES NO
5. Armed Forces
5 Petitioner is 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
Respondent is an active duty member of the armed forces.
YES NO UNKNOWN
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 the 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 at this time because:
8. Other Proceedings
a. A separate court case for marriage dissolution, 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:
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Open Closed Unknown or
b. The County has 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 file number is .
The case is Dismissed or Pending or an Order for Support was issued.
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 file number is
b. The Order for Protection include an order to pay child support. YES NO
10. Child Protection Court Case
6 There is a Child Protection court case involving the parties’ joint child(ren) taking place in
Minnesota or another state. YES NO
7 If YES , the case is in County in the State of
__________________ and the Court file number is . The
name of the child or children involved in the Child Protection Court case is:
11. Children Petitioner and Respondent have Together (Joint Children)
a. Are there any children born to or adopted by Petitioner and Respondent together, either
before or during the marriage? YES NO If YES,
Full Name of
Child Date of
Birth Age Child Currently Lives With
Petitioner Respondent Both
parents
OR _______________________(write in
name)
Petitioner Respondent Both parents
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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 Petitioner and Respondent 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:
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 born to or adopted by Petitioner and Respondent 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 is pregnant.
b. If Petitioner is pregnant answer (i) and (ii):
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(i) The date the baby is due is
Month Day Year
(ii) Do Petitioner and Respondent agree that the spouse is the biological father of the
unborn child? YES NO
If NO, Petitioner Respondent claims husband is not the biological father
of the child.
c. Respondent is Pregnant. YES NO UNKNOWN
d. If Respondent is pregnant answer (i) and (ii):
(i) The date the baby is due is
Month Day Year
(ii) Do Petitioner and Respondent agree that the spouse is the biological father of the
unborn child? YES NO
If NO, Petitioner Respondent claims husband is not the biological father
of the child.
14. Petitioner’s Children from Other Relationship (Non-Joint Children)
a. Does Petitioner have minor child(ren) born prior to the marriage from another marriage
or relationship? YES NO
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 Petitioner? Is Petitioner 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 Petitioner given birth, since marrying Respondent, to a minor child who is not a
child of the Respondent? 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 Petitioner since
marrying Respondent, who is not a child of the Respondent :
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Full Name of Child
and Age Date of
Birth Does Child Live
with Petitioner? Is Petitioner 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 Respondent as the father of
the child(ren) listed in (i) above? YES NO
If YES , attach a copy of the Order. The Order is for: _______________________
Full Name of Child(ren)
(iii) Have the Petitioner and biological Father signed a Minnesota Recognition of
Parentage for any of the children listed in (i) above? YES NO
(iv) Has the Respondent 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
submit a copy of the "Husband's Non-Paternity Statement."
If NO, why not?
15. Respondent’s Children from Other Relationship (Nonjoint Children)
a. Does Respondent have minor child(ren) born prior to the marriage from another
marriage or relationship? YES NO
If YES , the full name, date of birth and age of each child born prior to the marriage is:
Full Name of Child and
Age Date of
Birth Does Child Live
with Respondent? Is Respondent 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 Respondent given birth, since marrying Petitioner, to a minor child who is not a
child of the Petitioner? YES NO
If YES , answer (i) , (ii), (iii) and ( iv):
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(i) List the full name, date of birth and age of each child born to Respondent since marrying
Petitioner, who is not a child of the Petitioner:
Full Name of Child and
Age Date of
Birth Does Child Live
with Respondent? Is Respondent 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 Petitioner as the father
of the child(ren) listed in (i) above? YES NO
If YES , attach a copy of the Order. The Order is for: _______________________
Full Name of Child(ren)
(iii) Have the Respondent and biological Father signed 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 submit a copy of the Recognition of Parentage.
If NO , why not?
(iv) Has the Petitioner 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 submit a copy of the “Husband’s Non-Paternity Statement.”
If NO, why not?
16. Custody
It is in the child’s best interests and we agree that legal custody be granted as follows:
(check one)
Joint legal custody to both parents
Sole legal custody to Petitioner Respondent
It is in the child’s best interests and we agree that physical custody be granted as follows:
(check one)
Joint physical custody to both parents
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Sole physical custody to Petitioner Respondent
17. Parenting Time
a. It is in the best interests of the children that:
Petitioner's parenting time with the joint children be: (check one)
unsupervised supervised reserved
Respondent's parenting time with the joint children be: (check one)
unsupervised supervised reserved
If parenting time is unsupervised for both parents, skip to Question 18.
b. Supervision is necessary because unsupervised parenting time is likely to endanger the
child's physical or emotional health or impair the child's emotional development. The
circumstances supporting this finding are:
c. It is in the best interests of the child(ren) that supervision of parenting time be arranged
as follows: (State who should supervise parenting time, and if there is a cost involved, who
should pay the cost, and any other important details)
d. Parenting time should be reserved because:
18. 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. Petitioner receives public assistance from the State of Minnesota. YES NO
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If YES, the assistance is from __________________ County. (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. Respondent receives public assistance from the State of Minnesota.
YES NO UNKNOWN
If YES , the assistance is from __________________ County. (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. The joint children of the parties receive public assistance from the State of Minnesota.
YES NO UNKNOWN
If YES , the assistance is from __________________ County. (Check all that apply):
MFIP Medical Assistance Tribal TANF MinnesotaCare
IV-E Foster Care
19. 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 (SSI). NO YES in the
amount of $___________per month.
b. Respondent receives Supplemental Security Income (SSI)? NO YES in the
amount of $___________per month.
c. The joint children of the parties receive Supplemental Security Income (SSI).
NO YES in the amount of $___________per month. What is the name of the
child receiving SSI?____________________________________________________
20. School
Petitioner is 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
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c. The type of degree expected is____________________________and the expected
graduation date is __________________________.
Respondent is 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 __________________________.
21. Petitioner’s Employment
a. Petitioner is employed. YES NO
b. Petitioner is self-employed. YES NO
c. Petitioner is working at least 40 hours per week. YES NO
If Petitioner is unemployed or working less than 40 hours/week, answer these questions:
i. Why is Petitioner unemployed or working less than 40 hours/week.
ii. What is Petitioner's past work experience (type of jobs, hours, pay, length of time at
the job) and what are Petitioner's professional qualifications or licenses?
d. 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
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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 1 st
Job 2 nd
Job
Is Petitioner paid by the hour or
salaried? hourly salary hourly salary
What is the average number of hours
Petitioner works per week? ________________hours ________________hours
How much overtime pay does
Petitioner receive per week on
average? $_____________________ $____________________
Does Petitioner receive bonuses?
Yes No If Yes, how much was
received in bonuses last year?
$_____________
How much do you expect to
receive this year?
$___________ If Yes, how much was received
in bonuses last year?
$_____________
How much do you expect to
receive this year?
$___________
22. Petitioner’s Income
Source of Income Amount Per Month (or zero) before
deductions/taxes
Self Employment Income $________________ per month
Self Employment income means gross receipts minus costs of goods sold
minus ordinary and necessary business expenses.
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
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
Social Security Retirement, Survivors or Disability
Income (RSDI) (do not include SSI) $_________________per month
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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 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 Petitioner is court-ordered
to pay for any nonjoint child(ren) $________________ per month
Enter the amount of spousal maintenance Petitioner is court-ordered
to pay to a current or former spouse $________________ per month
Enter the amount of Social Security or Veteran's Benefits received by a joint child
because of Petitioner's retirement, disability, or other eligibility
$________________ per month
Which parent receives the payment for the child?
Petitioner Respondent
23. Living Expenses for the Family
a. Petitioner and Respondent and their children are still living together. Current monthly
living expenses for the family total $
OR
b. Petitioner and Respondent are living separately. The monthly family living expenses
before separation totaled $ . At this time, Petitioner's separate
monthly living expenses total $____________, and Respondent's monthly living expenses
total $______________or are UNKNOWN. Of the total current monthly living
expenses for Petitioner, $_______________ 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 the children that live with Respondent, or this
is UNKNOWN.
24. Expenses for Special Needs for the Children
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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 #23) include the special needs
expenses for the child? YES NO
c. Does Respondent’s monthly living expense (stated at #23) include the special needs
expenses for the child? YES NO
25. Respondent’s Employment
a. Respondent is employed. YES NO UNKNOWN
b. Respondent is self-employed. YES NO UNKNOWN
c. Respondent is 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 experience (type of jobs, hours, pay, length of time
at the job) and professional qualifications or licenses?
d. 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
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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
Questions about Jobs 1 st
Job 2 nd
Job
Is Respondent paid by the hour or
salaried? hourly salary
Unknown hourly salary
Unknown
What is the average number of
hours Respondent works per
week? ________________hours
Unknown ________________hours
Unknown
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?
$___________
26. Respondent’s Income
Sources of Income Amount Per Month (or zero) 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.
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
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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 Respondent 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 Security or Veteran's Benefits provided to a joint child
because of Respondent's retirement, disability, or other eligibility
$_________________per
month
Which parent receives the payment for the child?
Petitioner Respondent
OR
The Court does not have detailed information about Respondent's income, but
finds that Respondent's pay is $________________ per week month year,
with bonuses, overtime or commissions 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
27. Child Care Costs
Are there child care costs for joint children because of work or school ?
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YES NO UNKNOWN
If YES,
a. How many of the joint children need child care? One Two Three ________
8 b. How much does the daycare center(s) or babysitter charge per month? $
c. Who pays the child care costs?
9 Petitioner pays $ per month
10 Respondent pays $ per month
11 The County pays $ per month through a subsidy or child
care assistance.
12 If the County pays, who applied for the child care assistance?
13 Petitioner Respondent There is no county assistance
14
28. Health Care Coverage
a. Who receives Minnesota Care or Medical Assistance?
Petitioner Respondent Joint Children No one
b. Does Petitioner 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
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
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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?
$____________per month for single coverage
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$____________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
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
g. Other:
29. Spousal Maintenance
Petitioner and Respondent can each pay their own living expenses and do not need
spousal maintenance at this time, or in the future.
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:
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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. Respondent has the 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:
Petitioner has the ability to pay Respondent $_____________per month for spousal
maintenance.
30. 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 Petitioner or Respondent together or separately:
Type of
Vehicle (car,
boat, truck etc.) Year/Make/
Model Name(s) on
Title Value Balance
Owed Monthly
Payment
$ $ $
$ $ $
$ $ $
$ $ $
31. Marital Property
Marital property means almost anything that you or your spouse now own that was received 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 .
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Has the marital property been divided already in a manner satisfactory to Petitioner and
Respondent? YES NO
If NO , Petitioner requests the following marital property:
If NO , Respondent requests the following marital property:
32. 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:
b. Does Respondent have non-marital property? YES NO UNKNOWN
If YES, list Respondent’s non-marital property:
_____________________________________________________________________
33. Cash & Accounts – Not including Pension and Employer-Funded Retirement
Accounts
Does Petitioner have money in banks, savings, cash or investments? YES NO
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Does Respondent have money in banks, savings, cash or investments? YES NO
UNKNOWN
If YES,
a. List all accounts owned by one spouse alone or owned by both spouses jointly including
those opened after separation. “Type of account” means checking, savings, money market
accounts, certificates of deposit, stocks, bonds, stock options, mutual funds, savings bonds,
and Treasury Bills, etc. Use Confidential Information Form 11.1 (CON111) 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
#37.
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 $ OR UNKNOWN.
34. B usiness Interest
Does Petitioner have an interest in a business? YES NO
Does Respondent have an interest in a business? YES NO UNKNOWN
If YES, the name of the business is ____________________________, the address is
_________________________________________________________________________
and the value is $________________. This value is based on:
35. Manufactured Home
Does Petitioner own a manufactured home? YES NO
Does Respondent own a manufactured home? YES NO UNKNOWN
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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 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 36.
36. Real Property - Land, Buildings, Contracts for Deed
All real property now owned by Petitioner or Respondent together or separately must be listed.
Include real property acquired before the marriage, during 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 his/her own name or with someone
other than Petitioner? YES NO UNKNOWN
d. How many properties are owned by Petitioner and Respondent in total?
None One Two Three _______
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If Petitioner or Respondent 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 Information page for each piece of property.
Staple the additional sheets to this Decree, and label each sheet "Attachment to Findings of
Fact, Conclusions of Law, Order for Judgment, Judgment and Decree 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
2 nd
Mortgage: Amount currently owed $ and name of lender
Other mortgages or loans:
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6. Current Market Value of this property: $
How was this value determined?
7. This property is the homestead: _______Yes _________No
37. Retirement Plans
a. Does Petitioner have 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. Has 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. Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other)
YES NO UNKNOWN
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:
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d. Has Respondent , or Respondent’s past or present employer, union, or other group, paid
money in
