Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 1 of 13
IN THE COURT OF COMMON PLEAS
Division
COUNTY, OHIO
:
Plaintiff/Petitioner : Case No.
:
Street Address :
: Judge
City, State and Zip Code :
:
and : Magistrate
:
:
Plaintiff/Petitioner :
:
Street Address :
:
City, State and Zip Code :
Instructions: This form is used to present an agreement to the Court regarding spousal support, the division of
personal property, real estate , and debts resulting from the termination of marriage. If the parties have any minor
child(ren), child (ren) with disabilities, or the Wife is pregnant, a Shared Parenting Plan (Uniform Domes tic Relations
Form 17) or Parenting Plan (Uniform Domestic Relations Form 18) must be attached.
SEPARATION AGREEMENT
The parties, , Husband, an d
, Wife, state the following .
1. The parties were married to one another on (date of marriage)
in (city or county , and state), and request
that the termination of marriage be the date of final hearing or as s pecified:
2. The parties intend to live separate and apart.
3. Each part y has made full and complete disclosure to the other of all marital property, separate
property, and any other assets, debts , income, and expenses.
4. Neither party has knowledge of any other propert y and debts of any kind in which either party has an
interest.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 2 of 13
5. Each party has had the opportunity to value and verify all marital property, separate property, and
debts.
6. A party’s willful failure to disclose may result in the Court awarding the other party three times the
value of the property, assets, income, or expenses that were not disclosed by the other party.
7. This Agreement addresses spousal support , property , and debt division.
8. This written Agreement is the complete agreement of the parties.
9. There are no other representations, agreements, statements, or prior writing s that shall have any
effect on this Agreement.
10. Each party fully understands the Agreement and has knowingly and voluntarily signed the
Agreement.
11. No change to the terms of this Agreement shall be valid unless in writing and knowingly and
voluntarily signed by both parties.
The parties agree as follows:
FIRST: SEPARATION
The parties shall live separate and apart. Neither party shall interfere with the activities, personal life, or
privacy of the other; harass the other, nor engage in any conduct calculated to restrain, embarrass, injure,
or hinder the other in any way.
SECOND: PROPERTY
Marital property as defined in R.C. 3105.171 is property owned by either or both spouses and propert y
in which either spouse has an interest in the property. Separate property as defined in R.C. 3105.171
is real or personal property that w as inherited, acquired by one spouse prior to the date of marriage,
acquired after a decree of legal separation under R.C. 3107.17, excluded by a valid antenuptial agreement,
compensation for personal injury, except for loss of marital earnings and compensation for expenses paid
from marital assets, or any gift of property that was given to only one spouse. If separate property is
involved, the owner should consider consulting an attorney. The party not receiving the separate property
waives all interest in the property.
A. Real Estate ( select one ):
Real estate includes lands, mortgaged properties, buildings, fixtures attached to buildings, attached
structures (for example, garage, in -ground pool), condominiums, time shares, mobile homes, na tural
condition stakes (for example, gas, oil, mineral rights , existing soil, including trees and landscape), and
inheritance rights in real estate. The property’s legal description is on the deed or m ortgage papers.
1. The parties do not own any real estate.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 3 of 13
2. Marital Real Estate
The parties owned real estate in one or both of their names and agree to award it as follows.
A legal description of the property must be attached. (Attach a copy of the property’s deed or
mortgage papers.)
Location of Property Awarded to
3. Each party shall pay and hold the other harmless from any debt owing on real estate he/ she
receives unless otherwise stated in this Agreement.
4. Other debt payment arrangements, including refinancing:
If the real estate is not in the name of the party to whom it is awarded, th e parties shall make
arrangements to transfer the property to the proper party as soon a s possible.
B. Titled Vehicles (select one):
Titled vehicles include boats, trailers, automobiles, motorcycles, trucks, mobi le homes, golf carts,
motor scooters, sport utility vehicles (SUV), recreational vehicles (RV), all purpose vehicles (APV).
Provide vehicle model, make, year , and serial number for all titled vehicle(s) that will be transferred.
1. The parties do not own any titled vehicle(s) in either party’s name.
2. The titled vehicle(s) has/have alrea dy been divided or transferred, including all rights, title and
interest in the vehicle(s) and is/are in the possession of the proper party. The parties are s atisfied with
the division.
3. The parties own titled vehicle(s) which has/ have not been divided or transferred.
Husband shall receive the following vehicle(s), free and clear of any claims from the Wife:
and Wife shall receive the following vehicle(s), free and clear of any claims of the Husban d:
4. Each party shall pay for and hold the other harmless from any debt owing on the titled vehic le(s)
he/she receives unless otherwise stated in this Agreement.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 4 of 13
5. Other debt payment arrangements regarding titled vehicle(s):
If the vehicle’s title is not in the name of the party to whom the vehicl e is awarded, the current title
holder shall transfer that title to the proper party as soon as the title is available for transfer. If title
cannot be transferred immediately to the party to whom the vehicle is awarded, the party holding
the title shall make the following arrangements to obtain and pay for lice nse plates, registration,
and insurance:
C. Household Goods and Personal Property (select one):
Household goods and personal property include appliances, tools, air conditioner window units,
doghouses, lawn mowers, riding lawn mowers, above ground pools, safety deposit boxes, jewe lry,
furniture, refrigerators, silverware, collections, china, and books.
1. The household goods and personal property are already divided and in the possession of the
proper party. The parties are satisfied with the division.
2. The parties have household goods and personal property which have not been divided.
Husband shall have the following:
and Wife shall have the following:
3. Delivery or pick -up of household goods and personal property shall be as follows:
4. Each party shall pay for and hold the other harmless from any debt owing on the household goods
and personal property he/she receives unless otherwise stated in this Agreement.
5. Other debt arrangements regarding household goods and personal property:
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 5 of 13
The parties shall make arrang ements to transfer possession of the household goods and personal
property to the proper party as soon as possible.
D. Financial Accounts (select one):
Financial accounts include checking, savings, certificates of deposit, money market account s, medical or
health savings accounts, education or college saving plans (for example, 529 Plan) and trus ts.
1. The parties do not have any financial accounts.
2. The parties have financial accounts and agree the accounts are already divided and in the
name of the proper party. The parties are satisfied with the division.
3. The parties have financial accounts which are not divided.
Husband shall receive the following:
Institution Current Name( s) on Account Type of Account
checking saving
other:
checking saving
other:
checking saving
other:
and Wife shall receive the following:
Institution Current Name(s) on Account Type of Account
checking saving
other:
checking saving
other:
checking saving
other:
4. Each party shall pay for and hold the other harmless from any debt owing on the fin ancial accounts
he/she receives unless otherwise stated in this Agreement.
5. Other arrangements regarding financial accounts:
The parties shall make arrangements to transfer the financial accou nts to the proper party as
soon as possible.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 6 of 13
E. Stocks, Bonds, Securities , and Mutual Funds (select one):
1. The parties do not have any stocks, bonds, securities , or mutual funds.
2. One or both parties has/have stocks, bonds, securities , or mutual funds which are already divided
and in the name of the proper party. The parties are satisfied with the division.
3. One or both parties has/have stocks, bonds, securities , or mutual funds which are not divided.
Husband shall receive the following:
Institution Current Name(s) on Account Number of Shares
and Wife shall receive the following:
Institution Current Name(s) on Account Number of Shares
4. Each party shall pay for and hold the other harmless from any debt owing on the stocks, bonds ,
securities , or mutual funds he/she receives unless otherwise stated in this Agreement.
5. Other arrangements regarding the stocks, bonds, securities , or mutual funds:
The parties shall make arrangements to sell or transfer the stocks, bonds, securities, or mutual
funds to the proper party as soon as possible.
F. Business Interests (select one):
1. The parties do not have any business intere sts.
2. One or both parties has/have business interests and which are already divided and in the name of
the proper party. The parties are satisfied with the division.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 7 of 13
3. One or both parties has/have business interests which have not been divided.
Husband shall receive the following:
Name of Business Ownership Interest
and Wife shall receive the following:
Name of Business Ownership Interest
4. Each party shall pay for and hold the other harmless from any debt owing on the business int erests
he/she receives unless otherwise stated in this Agreement.
5. Other arrangements regarding business interests:
The parties shall make arrangements to transfer the business intere sts to the proper party as soon
as possible.
G. Pension, Profit Sharing, IRA, 401(k) , and Other Retirement Plans (select one ):
1. The parties do not have any pension, profit sharing, IRA, 401(k) , or other retirement plans.
2. The pension(s), profit sharing, IRA, 401(k) , or other retirement plans are already divided and in
the proper party’s name. The parties are satisfied with the division.
3. The parties have pension(s), profit sharing, IRA, 401(k), or other retirement plans which have not
been divided.
Husband shall receive the following:
Company Name(s) on Plan Amount/Share
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 8 of 13
and Wife shall receive the following:
Company Name(s) on Plan Amount/Share
4. Each party shall pay for and hold the other harmless from any debt owing on the pension(s), pr ofit
sharing, IRA, 401(k), or other retirement plans he/she receives unless otherwise stated in this
Agreement .
5. Other arrangements regarding pension(s), profit sharing, IRA, 401(k) , or other retirement plans:
The parties shall make arrangements to transfer interest in the pensi on(s), profit sharing, IRA,
401(k), or other re tirement plans to the proper party as soon as possible.
A Qualified Domestic Relations Order (QDRO) or Division of Prope rty Order (DOPO) may be
necessary to divide some of these assets. If so, the QDRO and DOPO wil l be prepared by:
and submitted to the Court within 90 days after the final hearing . Expenses of preparation
shall be paid as follows:
The Court retains jurisdiction to interpret and enforce the terms of the documents of transfer.
H. Life Insurance Policies (select one):
1. The parties do not have any life insurance policy(ies) with a cash value.
2. The parties have life insurance policy(ies) and agree the cash value of all life insurance polic y(ies)
has/have already been divided. The parties are satisfied with the division.
3. The parties’ life insurance policy(ies) has/have not been divided.
Husband shall receive the following policy(ies), free and clear of any claims of the W ife:
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 9 of 13
and Wif e shall receive the following policy(ies), free and clear of any claims of the Husband:
4. Each party shall pay for and hold the other harmless from any debt owing on the life insurance
policy(ies) he/she receives unless otherwise stated in this Agreement.
5. Other arrangements regarding life insurance policy(ies):
The parties shall make arrangements to transfer interest in the life in surance policy(ies) to the
proper party as soon as possible.
I. Other Property (selec t one):
1. The parties do not have any other property.
2. The property shall be awarded as follows:
Description of Property To Be Kept By
Husband Wife Ot her
Husband Wife Other
Husband Wife Other
Husband Wife Other
3. Each party shall pay for and hold the other harmless from any debt owing on the property he/s he
receives unless oth erwise stated in this Agreement .
4. Other arrangements regarding the property above:
The parties shall make arrangements to transfer interest in the property listed above to the proper
party as soon as possible.
THIRD: DEBTS (select one ):
The parties do not have any debts.
Each party shall pay all debts incurred by him or her individually and in their individual name and shall
hold the other party harmless for these debts.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 10 of 13
The parties have the following debts and have agreed to the payment of all debts owed, and agree to
hold the other party harmless on those debts, as follows:
Creditor Purpose of Debt Balance Who Will Pay
Husband W ife
Husband W ife
Husband W ife
Husband W ife
Bankruptcy (select one):
The Court will retain jurisdiction to enforce payment of debt obligations, in the event a party files
bankruptcy, including, but not limited to, the ability to determ ine the debt assigned is in the nature
of maintenance, necessity or support and is therefore nondischargeable in bankruptcy, and/or
making a future spousal support order, regardless of the spousal support order set forth below
under FOURTH: SPOUSAL S UPPORT.
Nothing in this order shall prevent the Plaintiff and Defendant from being fully discharged
from the debts allocated in this order in a bankruptcy proceeding except for any orders expressly for
spousal support and the following debts:
Neither party shall incur liabilities against the other party in the future and each shall pay a ny debt
incurred by him or her individually after the date of this agreement.
FOURTH: SPOUSAL SUPPORT
A. Spousal Support Not Awarded
Neither the Husband nor Wife shall pay spousal support to the other. The Court shall not
retain jurisdiction to modify spousal support, except as set forth above under THIRD: DEBT .
B. Spousal Support Awarded
The Husband Wife shall pay spousal support to the Husband W ife
in the amount of $ per month plus 2% processing charge
for a total of $ per month, commencing o n and
due on the day of the month. This spousal support shall continue
indefinitely for a period of .
C. Method of Payment of Spousal Support (select one):
If there are no child(ren), the spousal support payment shall be made directly to
the Plaintiff Defendant.
The spousal support payment, plus 2% processing charge, shall be made to the Ohio Child
Support Payment Central, P. O. Box 182372, Columbus, Ohio 43218-2372, as administered through
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 11 of 13
the County Child Support Enforcement Agency by income withholding
at his/her place of employment.
The Court shall not retain jurisdiction to modify spousal sup port.
The Court shall retain jurisdiction to modify the amount duration of the spousal support
Order.
D. Termination of Spousal Support
This spousal support shall terminate sooner than the above stated date upon the Plaintiff’s or the
Defendant’s death or in the event of the following (check all that apply):
The cohabitation of the person receiving support in a relationship comparable to marriage.
The remarriage of the person receiving support.
Other (specify):
E. Deductibility of Spousal Support for All Tax Purposes (select one):
The spousal sup port paid shall be deducted from income to the person paying the support and
included in income by the person receiving the support.
The spousal support paid shall be included in income of the person paying the support.
F. Other orders regarding spousal support (specify):
G. Arrearage
Any temporary spousal support arrearage will survive this judgment entry.
Any temporary spousal support arrearage will not survive this judgment entry.
Other:
FIFTH: NAME
shall be restored to
the prior name of:
SIXTH: ALLOCATION OF PARENTAL RIGHTS AND RESPONSIBILITIES, PAR ENTING TIME, CHILD
SUPPORT AND HEALTH CARE
The parties do not have child(ren) subject to the jurisdiction of the Court.
The parties have minor child(ren) subject to the jurisdiction of the Court, and
a Parenting Plan or Shared Parenting Plan is attached.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 12 of 13
SEVENTH: OTHER
The parties agree to the following additional matters:
EIGHTH: NON-USE OF OTHER’S CREDIT
From now on, neither party shall incur any debt or obligation upon the credit of the other or in their joint
names. If a party incurs such a debt or obligation that party shall repay, indemnify, and hol d the other
harmless as to any such debt or obligation. All joint credit card accounts shall be immediatel y cancelled,
and the cards shall be immediately destroyed.
NINTH: INCORPORATION INTO DECREE/EFFECTIVENESS OF AGREEMENT
If one or both of the parties institute or have instituted proceedings for dissolution, divor ce, or separation,
this Agreement shall be presented to the Court with the request that it be adjudicated to be fair, just, and
proper, and incorporated into the decree of the Court.
TENTH: PERFORMANCE OF NECESSARY ACTS
Upon execution and approval of this Agreement by the Court, each party shall deliver to the ot her party, or
permit the other party to take possession of all items of property to which each is entitled under the terms
of this Agreement, and shall make all periodic payments required under the terms of this Agreement.
Upon failure of either party to execute and deliver any deed, conveyance, title, certificate or other
document or instrument to the other party, an order of the Court incorporating this Agreement shall
constitute and operate as a properly executed document, and the County Auditor, County Recorder, Clerk
of Courts and/or all other public and private officials shall be authorized and directed to accept a properly
certified copy of a court order incorporating this Agreement, a properly certified copy of the Agreement or
an order of the Court in lieu of the document regularly required for the conveyance or transfer.
ELEVENTH: SEVERABILITY
If any provision of this Agreement is held to be invalid or unenforceable, all other prov isions shall continue
in full force and effect.
TWELFTH: APPLICABLE LAW
All of the provisions of this Agreement shall be construed and enforced in accordance with t he laws of the
State of Ohio.
THIRTEENTH: MUTUAL RELEASE
Except as otherwise provided, the parties do release and forever discharge each other from any an d all
actions, suits, debts, claims, demands, and obligations whatsoever, both in law and in equity, which either
of them ever had, now has, or may have or assert against the other upon or by reason of any matter or
cause to the date of the execution of this Agreement.
Supreme Court of Ohio Uniform Domestic Relations Form – 16
SEP AR ATION AGREEM ENT
Approved under Ohio Civil Rule 84
Effective Date: 7/1/2013 Page 13 of 13
Each party waives all rights of inheritance and the right to share in the estate of the other, and waives all
rights which would otherwise be available as a surviving spouse, except payments or right s included in this
Agreement.
Your Signature (Husband) Your Signature (Wife)
Date Date
