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) Stipulated Findings of Fact,
Conclusions of Law, Order
for
and Judgment, Judgment and Decree
(Minn. Gen. R. Prac. 308.04)
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
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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:________________________________
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. 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 incorporated the stipulated facts and
terms of the parties’ agreement. Respondent and Petitioner have s igned an
Acknowledgement regarding this agreement, 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: ________________________
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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 submitted along
with the Petition.
2. Information about Respondent
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”:
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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
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 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
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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 because:
8. Other Proceedings
A separate court case for marriage dissolution, legal separation, or annulment has 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:
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 .
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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 Respndent 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
____________________
_
(write in name)
Petitioner Respondent
Both parents
____________________
__
(write in name)
Petitioner Respondent
Both parents
____________________
____(write in name)
Petitioner Respondent
Both parents
____________________
__
(write in name)
Petitioner Respondent
Both parents
____________________
__
(write in name)
If a child is living with someone other than a parent, write the child's address below:
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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. YES NO
b. If Petitioner 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.
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
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(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 (Nonjoint 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
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 :
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)
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(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):
(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
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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
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
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If parenting time is unsupervised for both parents, skip to Question 18.
b. supervised parenting time
(Option 1) 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:
(Option 2) We agree that supervised parenting time is necessary because
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)
c. Reserved Parenting time
We agree that parenting time should be reserved because:
18. Public Assistance from State of Minnesota
Note: 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
If YES, the assistance is from __________________ County. (Check all that apply):
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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
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. Petitioner’s Employment
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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 currently has more than two jobs, 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
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
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receive per week on average? $___________________ $___________________
Does Petitioner receive bonuses?
Yes No 1 st
Job
Yes No 2 nd
Job
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?
$___________
21. 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
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
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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
22. 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 $______________. 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.
23. Expenses for Special Needs for the Children
a. Is there a joint 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 #22) include the special needs
expenses for the child? YES NO
c. Does Respondent’s monthly living expense (stated at #22) include the special needs
expenses for the child? YES NO
24. Respondent’s Employment
a. Respondent is employed: YES NO
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b. Respondent is Self-Employed: YES NO
c. Respondent is working at least 40 hours per week? YES NO
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 currently has more than two jobs, use an attachment for the
additional jobs.)
_____________________________________________________________________
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
Questions about Jobs 1 st
Job 2 nd
Job
Is Respondent paid by the hour
or salaried? hourly salary hourly salary
What is the average number of
hours Respondent works per
week? ________________hours ________________hours
How much overtime pay does
Respondent receive per week
on average? $_____________________ $____________________
Does Respondent receive If Yes, how much did If Yes, how much did
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bonuses?
Yes No 1 st
Job
Yes No 2 nd
Job
Respondent receive in
bonuses last year?
$___________
How much does Respondent
expect to receive this year?
$___________ Respondent receive in
bonuses last year?
$_________
How much does Respondent
expect to receive this year?
$___________
25. 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
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 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
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Enter the amount of Social Security or Veteran's Benefits received by a joint child
because of Respondent's retirement, disability, or other eligibility
$_________________ per month
Which parent receives the payment for the child?
Petitioner Respondent
26. Child Care Costs
Are there child care costs for joint children because of work or school ? YES NO
If YES,
a. How many of the joint children need child care? One Two Three ________
b. How much does the daycare center(s) or babysitter charge per month? $
c. Does the County child support agency pay for child care through a subsidy or
child care assistance? Yes, child care assistance is being received.
Petitioner’s Respondent’s co-pay for child care per month is $
No, there is no county child care assistance received.
d. The parties agree that Petitioner should pay $ per month for his/her
proportional share of child care costs and Respondent should pay $
per month for his/her proportional share of child care costs. These amounts
are are not based upon calculations using the child support guidelines worksheet.
27. 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?
$____________per month for single coverage
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$____________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
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 If No, 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
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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 If No, 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
$____________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 joint children
currently have health coverage.
g. Other:
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28. Basic Support: Basic support is for a child’s housing, food, clothing, transportation,
education costs, and other expenses related to the child’s care.
Petitioner Respondent shall pay basic support to the other party
in the amount of $ per month by the frst day of the month,
starting the frst month after entry of the judgment for divorce. Payment
shall be through income withholding. This amount is based on the
calculations from the child support guidelines worksheet, which is attached
and incorporated into this Marital Termination Agreement.
Petitioner Respondent shall pay basic support to the other party
in the amount of $ per month by the frst day of the month,
starting the frst month after entry of the judgment for divorce. Payment
shall be through income withholding. This amount is a deviation from
guidelines. The parties agree that this amount adequately meets the
needs of the child(ren) and is in the best interests of the child(ren).
29. Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.
Check only one box:
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 additional support in the form of spousal maintenance. Each
party has made a full and fair disclosure of all income and assets and liabilities that 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)
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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. 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
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
$ $ $
$ $ $
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$ $ $
$ $ $
$ $ $
30. 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 .
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:
_________________________________________________________________________
_________________________________________________________________________
31. 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
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If YES, list Respondent’s non-marital property:
32. Cash & Accounts – Not including Pension and Employer-Funded Retirement
Accounts
Does Petitioner have money in banks, savings, cash or investments? YES NO
Does Respondent have money in banks, savings, cash or investments? YES NO
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
#36.
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 $ .
33. B usiness Interest
Does Petitioner have an interest in a business? YES NO
Does Respondent have an interest in a business? YES NO
If YES, the name of the business is ____________________________, the address is
_________________________________________________________________________
and the value is $________________. This value is based on:
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34. Manufactured Home
Does Petitioner own a manufactured home? YES NO
Does Respondent own a manufactured home? YES NO
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 35.
35. 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
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b. Does Petitioner own real property solely in his/her own name or with someone other
than Respondent? YES NO
b. Does Respondent own real property solely in his/her own name or with someone
other than Petitioner? YES NO
c. How many properties are owned by Petitioner and Respondent in total?
None One Two Three _______
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 Stipulated
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)
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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:
6. Current Market Value of this property: $
How was this value determined?
7. This property is the homestead: _______Yes _________No
36. 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 o
