NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA.
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FM -DivB -201 Final Decree of D ivorce [S ET B] (R ev. 01 -2016)
AND IN THE INTEREST OF:
1. _________________________ 2. _________________________ 3. _________________________
4._________________________ 5. _________________________ 6. _________________________
Final Decree of Divorce
A hearing took place on ______ _________________ _.
Date
There was no jury . Neither the husband nor wife asked for a jury .
1. Appearances
Petitioner
The Petitioner’s name is: _____________________________________________________________.
First Middle Last
The Petitioner is the : (C heck one box .)
Husband Wife
(Check one box .)
The Petitioner was present, representing him/herself , and announced ready for trial .
The Petitioner was present, representing him/herself, and agreed to the terms of this Final Decree of
Divorce (called “Decree
” throughout this document) .
The Petitioner was not present but has signed on page 2 4, agreeing to the terms of this Decree.
Respondent
The Respondent’s name is: ___________________________________________________________.
First Middle Last
The Respondent is the : (C heck one box .)
Husband Wife
(Check one box .)
The Respondent was present, representing him/herself, and announced ready for trial .
The Respondent was present, representing him/herself , and agree d to the terms of this Decree .
The Respondent was not present but filed a n Answer or Waiver of Service and has signed on page
24 agreeing to the terms of this Decree.
The Respondent was not present but filed a Global Waiver of Service that waived Respondent’s right
to notice of this hearing and did not otherwise appear.
The Respondent was not present but was served and has defaulted. The Petitioner has filed a
Certificate of Last Known Address and a Military Status Affidavit .
Cause Number:
IN THE MATTER OF THE MARRIAGE OF
Petitioner:
In the ______________ (Court Number)
District Court
County Court at Law
County, Texas
Print first, middle and last name of the spouse who filed for divorce.
And
Respondent: Print first, middle and last name of other spouse.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
2.
Record
A Court reporter recorded today’s hearing.
A Court reporter did not record today’s hearing because the Husband, W ife, and judge agreed not to
make a record.
A Statement of the Evidence was signed by the Court.
3. Jurisdiction
The Court heard evidence and finds that it has jurisdiction over this case and the parties, t hat the
residency and notice requirements have been met, and the Petition for Divorce meets all legal
requirements.
The Court finds that : (Check one
box .)
it has been at least 60 days since the Petition for Divorce was filed .
the 60 day waiting period is not required because: (Check one box .)
Petitioner has an active Protective Order under Title 4 of the Texas Family Code or an active
magistrate’s order for emergency protection under Article 17.292 of the Texas Code of Criminal
Procedure , against Respondent because Respondent committed family violence during the
marriage.
Respondent has a final conviction or has received deferred adjudication for a crime inv olving
family violence against Petitioner or a member of Petitioner’s household.
4. Divorce
IT IS ORDERED that the Petitioner a nd the Respondent are divorced.
5. Children
5A. Children Husband and Wife Have Together
The Court finds that the Husband and W ife are the parents of the children listed below and that there are
no other children born to or adopted by Husband and Wife who are under 18 years old or
still in high
school .
(List all biological and adopted children you and your spouse have together who are under 18 or over 18 and still in high school.)
Child’s name Sex
Date
of Birth
Place
of Birth Social Security #
State
where
child
lives now
1 / /
2 / /
3 / /
4 / /
5 / /
6 / /
The Court finds that the re are no other court orders regarding any of the children listed above.
The Court fills out this box.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
5B.
Wife Not Pregnant
The Court finds that the W ife is not pregnant.
5C . Did the Wife have a Child with Another Man while Married to the Husband?
(Check one box.)
The Court finds that the Wife did not have any children with another man while married to the
Husband.
The Court finds that the Wife did have a child /children with another man while married to the
Husband. All of the children born during the marriage that are not the husband’s adopted or
biological children are named below:
Child’s name
Sex Date of Birth
1
2
3
4
5
The Court further finds that paternity of each child listed above has been established as set out
below:
(C heck one box below . Attach copy of court order or Acknowledgement and Denial of Paternity for each child. )
A court order has established that another man is the biological father and/or the Husband is not
the biological father of the child/ren listed here:
_____________________________________________________________________________.
A copy of the court order is attached to this Decree as Exhibit ___ .
An Acknowledgement of Paternity was signed by the biological father and a Denial of Paternity
was signed by the Husband for the child /ren listed here:
_____________________________________________________________________________.
Each Acknowledgment and Denial of Paternity was filed with the Vital Statistics Unit. A copy of
each Acknowledgment and Denial of Paternity is attached to this Decree as Exhibit(s) ________.
6. Parenting Plan
The Court finds that the following orders concerning the rights and duties of the Husband and W ife in
relation to their child/ren , including orders for conservatorship (custody ), possession and access
(visitation) , child support and medical support , are in the child /ren’s best interest .
The Court further finds that these orders constitute the parenting plan of the Court for the child /ren listed
by name in 5A above.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
7.
Conservatorship (Custody)
7A. Rights and Duties of Both Parents
The Court ORDERS that both parents always have the following rights: Texas Family Code 153.073
1.The right to receive information from the other parent or conservator about the child/ren’s health,
education, and welfare;
2. The right to talk or confer with the other parent, to the extent it is possible, about upcoming
decisions concerning the child/ren’s health, education, and welfare;
3. The right to have access to the child/ren’s medical, dental, psychological, and educational
re cords;
4. The right to talk or consult with the child/ren’s doctors, dentists, and psycholo gists;
5. The right to talk or consult with school officials, including teachers, and school staff, about the
child/ren’s welfare and educational status and school activit ies;
6. The right to attend the child/ren’s school activities;
7. The right to be designated as an emergency contact on their child/ren’s records;
8. The right to give consent for emergency medical, dental, and surgical treatment if the child/ren’s
health or safety is in immediate danger ; and
9. Each parent has the right to manage the child/ren’s estate(s) if he or she created it for the
child/ren or if that parent’s family created it for the child/ren.
The Court ORDERS that each
parent ha s the following rights and du ties when the parent is in possession
of the child /ren : Texas Family Code 153.074
1. The duty to care for, control, protect, and reasonably discipline the child/ren;
2. The duty to support the child /ren, including providing them with food, clothing, and shelter, and
medical and dental care that does not involve an invasive procedure ;
3. The right to consent to non -invasive medical and dental care for the child/ren; and
4. The right to direct the child/ren’s moral and religious training.
The Court ORDERS that each
parent always have the following duties: Texas Family Code 153.076
1.The Court ORDERS that each parent has the duty to inform the other parent in a timely manner
of significant information concerning the health, education, and welfare of the child/ ren.
2. The Court ORDERS that each parent has the duty to inform the other parent if the parent resides
with for at least thirty days, marries, or intends to marry a person who the parent kno ws is
registered as a sex offender under chapter 62 of the Code of Criminal Procedure or is currently
charged with an offense that would require the person to register as a sex offender under that
chapter, if convicted.
The parent is ORDERED to give this notice as soon as practicable, but no later than the 40 th
day
after the date the parent or conservator begins to reside with the person, or within 10 days of
marrying the person. The notice must include a description of the offense that required the
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
person to register as a sex offender
or the offense that the person is charged with that may
require the person to register as a sex offender.
WARNING: A PARENT/CONSERVATOR COMMITS AN OFFENSE PUNISHABLE AS A CLASS
C MISDEMEANOR IF THE PARENT/CONSERVATOR FAILS TO PROVIDE THIS NOTICE.
3. The Court ORDERS that each parent has the duty to inform the other parent if the parent
establishes a residence with a person who the parent knows is the subject of a final protective
order sought by an individual other than the parent that is in effect on the date the residence wi th
the person is established.
The parent is ORDERED to give this notice as soon as practicable but not later than the 30 th
day
after the date the parent establishes residence with the person who is the subject of the final
protective o rder.
WARNING: A PARENT/CONSERVATOR COMMITS AN OFFENSE PUNISHABLE AS A CLASS
C MISDEMEANOR IF THE PARENT/CONSERVATOR FAILS TO PROVIDE THIS NOTICE.
4. The Court ORDERS that each parent has the duty to inform the other parent if the conservator
resides with, or allows unsupervised access to a child by, a person who is the subjec t of a final
protective order sought by the parent after the expiration of the 60 -day period following the date
the final protective order is issued.
The parent is ORDERED to give this notice as soon as practicable but not later than the 90 th
day
after the date the protective order was issued.
WARNING: A PARENT/CONSERVATOR COMMI TS AN OFFENSE PUNISHABLE AS A CLASS
C MISDEMEANOR IF THE PARENT/CONSERVATOR FAILS TO PROVIDE THIS NOTICE.
5. The Court ORDERS that each parent of a child has the duty to inform the other parent of the child
if the parent is the subject of a final protective order issued after the date of the order establi shing
conservatorship.
The parent is ORDERED to give this notice as soon as practicable but not later than the 30 th
day
after the date the final protective order was issued.
WARNING: A PARENT/CONSERVATOR C OMMITS AN OFFENSE PUNISHABLE AS A CLASS
C MISDEMEANOR IF THE PARENT/CONSERVATOR FAILS TO PROVIDE THIS NOTICE.
Note: A person who is the subject of a final protective order is the person who the protective order is against.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
7B.
Parents Appointed Conservators
If the parents will be joint managing conservators, check box 7B(1) below and fill in the requested
information.
If one parent will be the sole managing conservator and the other will be the possessory conservator , skip
7B(1) . Go to the next page and check box 7B(2) . F ill in the information requested in box 7B2.
7B(1)
Joint Managing Conservators
The Court ORDERS that the parents are appointed Joint Managing Conservators and :
(Check 7B(1)(a) or 7B(1)(b) .)
7B(1)(a)
One Parent Has the Exclusive Right to Decide Where the Child/ren Live.
T he Court ORDERS that _________________________________ ________________
Print the name of the parent who
will decide where the child /ren live.
has the exclusive
right to designate the primary residence of the child /ren and that s /he :
(Check one box .)
may designate the child/ren’s residence without regard to geographic location .
must designate the child/ren’s residence within the following geographic area :
(Check one box .)
the school attendance zone of: _____________________________________.
this county. this county or count y adjacent to this county.
Texas. other : ____________________________________.
7B(1)(b )
Neither Parent Has the Exclusive Right to Decide Where the C hild/ren Live.
The Court ORDERS that neither parent has the exclusive right to designate the primary
residence of the children . However, both parents are ORDERED not to move the
children’s primary residence from the following geographic area:
(Check one box .)
the school attendance zone of: ___ ___________________________________ __.
this county. other : ______________ ______________________ .
The Court ORDERS that the parents, as Joint Managing Conservators , also have the rights
and duties as marked below. The right or duty listed in the 1 st
column shall be exercised by the
parent or parents as marked in the 2 nd
, 3 rd
, 4 th
, or 5 th
column.
(Check one box in each row.)
Mother
exclusively Father
exclusively Parents
jointly Parents
independently
1.the right to consent to invasive medical,
dental, and surgical treatment for the
child/ren
2. the right to consent to psychiatric or
psychological treatment for the child/ren
3. the right to receive child support and save
or spend these funds for the child/ren’s
benefit No No
4. the right to represent the child/ren in a
legal action and make important legal
decisions that affect the child/ren
5.the right to consent to a child’s marriage,
or to a child enlisting in the U.S. Armed
Forces
6. the right to make decisions concerning the
child/ren’s education
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
(Check one box in each row.)
Mother
exclusively
Father
exclusively
Parents
jointly
Parents
independently
7. the right to the services and earnings of
the child/ren
8. the right to make decisions for the
child/ren about their estates if required by
law (unless the child/ren have a guardian
or attorney ad litem or guardian of the
estate)
9. the duty to manage the child/ren’s estates
to the extent the estates have been created by the parents’ community or joint
property.
7B(2) Sole Managing Conservator and Possessory Conservator
The Court ORDERS that ____________________________________________________ is
(Print the name of the parent appointed Sole Managing Conservator of the children. )
appointed Sole Managing Conservator of the children.
The Court ORDERS that _____________________ _______________________________ is
(Print the name of the parent appointed Possessory Conservator of the children. )
appointed Possessory Conservator of the children.
The Court ORDERS that the Sole Managing Conservator has the following exclusive
rights and
duty:
1. the right to designate the primary residence of the child/ren without geographic restric tion;
2. the right to consent to medical, dental, and surgical treatment for the child/ren involving
invasive procedures;
3. the right to consent to psychiatric and psychological treatment of the child/ ren;
4. the right to receive child support and to save or spend these funds for the benefit of the
child/ren ;
5. the right to represent the child/ren in legal action and to make other decisions of
substantial legal si gnificance concerning the c hild/ren;
6. the right to consent to marriage and to enlistment in the United States Armed Forces ;
7. the right to make decisions concerning the child/ ren’s education;
8. the right to the services and earnings of the child/ren;
9. exce pt when a guardian of the chil d/ren’s estates or a guardian or attorney ad litem has
been appointed for the child /ren , the right to act as an agent of the child /ren in relati on to the
child /ren’s estates if the c hild/ren ’s action is required by a state, the United States, or a
foreign government;
10. the duty to manage the estates of the child /ren to the extent the estates have been created
by community property or the joint property of the parents .
7 C. Order Regarding Passports for the Children
The Court ORDERS that: (Check one box .)
Mother shall have the exclusive right to apply for and renew passports for the child/ren.
Father shall have the exclusive right to apply for and renew passports for the child/ren.
Neither parent has the exclusive right to apply for or renew passports for the child/ren. A par ent who
applies for or renews a passport for the child/ren must obtain the written consent of the other pare nt.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
8.
Possession and Access (Visitation)
The Court ORDERS that the parents shall have possession and access to the child /ren as ordered in the :
(Check one box . Attach the appropriate Possession Order to this Decree. Write Exhibit A at the top. )
Standard Possession Order attached as Exhibit A and fully incorporated into this Decree.
Modified Possession Order attached as Exhibit A and fully incorporated into this Decree.
Su pervised Possession Order attached as Exhibit A and fully incorporated into this Decree.
(Check only if needed. A ttach a Possession and Access Order for Child Under 3. Write Exhibit B at the top. )
The C ourt ORDERS that until a child is 3 years old, the parents shall have possession and access to
the child as ordered in the Possession and Access Order for Child Under 3 attached as Exhibit B and
fully incorporated into this Decree. The Court ORDERS that beginning on the child’s 3 rd
birthday , the
parents shall have possession and access to the child as ordered in the Possession and Access
Order attached as Exhibit A.
9. Child Support
9 A. Order to Pay Child Support
The Court ORDERS ___________________________________________________ (Obligor ) to pay
(Print the name of the parent who will pay child support.)
c hild support to _________________________________________________ (Obligee ) in the amount
(Print the name of the parent who will receive child support.)
and manner described below until one of the followin g events that terminate child support occurs for
each child listed in 5A above .
9B. Events that Terminate Child Support
The obligation to pay child support for a child terminates when:
● The child turns 18, unless when the child turns 18 he or she is enrolled and complying with
attendance requirements in a secondary school program leading toward a high school diploma or
enrolled in courses for joint high school and junior college credit then child support terminates at
the end of the month in which the child graduates. -or -
● The child marries, dies, or is emancipated by court order. -or -
● The child begins active duty in the United States armed forces. -or -
● A court terminates the parent -child relationship between the man ordered to pay child support and
the child based on genetic testing that determines the man is not the child’s father. -or -
● The person ordered to pay child support and the person ordered to receive child support marry or
remarry each other, unless a nonparent or agency has been appointed conservator of the child.
9C. Obligor and Obligee
The Court ORDERS that the parent ordered to pay child support in 9A above is the Obligor and will be
referred to as the “Obligor ” throughout this section .
The Court ORDERS that the parent ordered to receive child support in 9 A above is the Obligee and will
be referred to as the “Obligee” throughout this section .
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
9D.
Child Support Amount(s)
If only one child will receive support, check box 9D(1) and fill in the child support amount and start date .
If more than one child will receive support, check box 9D(2) and fill in the child support amounts and start date .
9D(1) For a Single Child
Obligor is ORDERED to pay $ ___________ _____ child support per month . The 1 st
payment is
due on ________________________ . A like payment is due on the 1st
day of each month
Month / Day / Yea r
a fter that until child support terminates for the child .
9D (2)
For Multiple Children
Obligor is ORDERED to pay $___________ _____ child support per month. The 1 st
payment is
due on ________________________ . A like payment is due on the 1st
day of each month after
Month / Day / Year
that until child support terminates for one child .
After child support terminates for one child, Obligor is ORDERED to pay $_ __________ ___
child support per month. The 1 st
payment is due on the 1 st
day of t he 1st
month after child
support terminates for one child. A like payment is due on the 1st
day of each month after that
until child support terminates for a second
child.
After child support terminates for two children, Obligor is ORDERED to pa y $_ ____________
child support per month. The 1 st payment is due on the 1 st day of t he 1st month after child
support terminates for a second child. A like payment is due on the 1st day of each month after
that until child support terminates for a third
child.
After child support terminates for three children, Obligor is ORDERED to pay $_____________
child support per month. The 1 st
payment is due on the 1 st
day of t he 1st
month after child
support terminates for a third child. A like payment is due on the 1st
day of each month after
that until child support terminates for a fourth
child.
After child support terminates for four children , Obligor is ORDERED to pay $______________
child support per month. The 1 st
payment is due on the 1 st
day of t he 1st
month after child
support terminates for a fourth child. A like payment is due on the 1st
day of each month after
that until child support terminates for a fifth
child.
After child support terminates for five children , Obligor is ORDERED to pay $______________
child support per month. The 1 st
payment is due on the 1 st
day of t he 1st
month after child
support terminates for a fourth child. A like payment is due on the 1st
day of each month after
that until child support terminates for a sixth
child.
Warning! Do not pay child support directly to the other parent. Send all child support payments to
the Texas Child Support Disbursement Unit, PO Box 659791, San Antonio, TX 78265. If you pay child
support directly to the other parent, you won’t get credit and you may have to pay again!
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
9E.
Place of Payment
The Court ORDERS Obligor to send all child support payments to the Texas C hild Support State
Disbursement Unit, PO Box 659791, San Antonio, TX 78265 , for distribution according to law.
The Court ORDERS Obligor to Include the following information with each payment:
● Name of parent ordered to pay child support, and
● Name of parent ordered to receive child support, and
● Cause Number and County of Decree or Order, and
● Attorney General Case Number, if applicable.
Payments should be made out to the Texas State Disbursement Unit or TX SDU .
9F. No Credit for Informal Payments
IT IS ORDERED that money paid by Obligor directly to Obligee or spent while in possession of the
child /ren does NOT count as child support and shall be deemed in addition to and not instead of the
support ordered in this order.
9G. Child Support Account / Fees
Each parent is ORDERED to:
● Fill out any forms necessary to set up a child support account, and
● Take the forms to the local Domestic Relations Office or county child support liaison w ithin 5 days
after the judge orders child support , and
● Pay when due all fees charged to that parent by the state disbursement unit and any other
agency authorized by law to a charge a fee for the collection and distribution of child support.
9H. Guideline or Non -Guideline Support
The Court finds that the child support ordered above is:
Guideline Support: The amount of child support is approximately the amount recommended by the
Texas Family Code Child Support Guidelines . See Texas Family Code, Chapter 154, Subchapter C.
Non-Guideline Support: The amount of child support differs significantly from the amount
recommended by the Texas Family Code Child Support Guidelines .
( If the amount ordered is not based on the guidelines, you must also provide the following information.)
The net monthly income/resources of the Obligor is $ __________________.
The net monthly income/resources of the Obligee is $ __________________.
Guideline c hild support would be ________ % of Obligor’s net
monthly resources, which is
$ ________________ per month.
The actual monthly child support amount ordered is $_______________ , which is_______ % of
Obligor’s net monthly income /resources.
Guideline child support would be unjust or inappropriate under the circumstances because:
9I. Income Withholding
IT IS ORDERED that any employer of Obligor is ordered to withhold child support from Obligor’s
disposable earnings.
If an income withholding for support order is served on Obligor’s employer, the employer shall withhold
child support payments from Obligor’s pay, and send it to the Texas Child Support Disbursement Unit,
PO Box 659791, San Antonio, TX 78265
, where the payments shall be recorded, and forwarded to
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
Obligee
. All child support withheld and paid in accordance with this order shall be credited against
Obligor’s child support obligation.
If the employer withholds less than 100% of the child support ordered, Obligor is ORDERED to send the
balance owed to the Texas Child Support Disbursement Unit, PO Box 659791, San Anto
nio, TX
78265.
If an income withholding for support order is not served on the employer, or if Obligor’s is self-employed
or unemployed, Obligor’s is ORDERED to send all child support payments to the Texas Child Support
Disbursement Unit, PO Box 659791, San Antonio, TX 78265
.
IT IS ORDERED that the Clerk of this Court shall cause a certified copy of the income wit hholding for
support order to be delivered to any employer of Obligor, if asked to do so by Obligor, Obligee, a
prosecuting attorney, the title IV -D agency, a friend of the Court, or a domestic relations office.
9J. Suspension of Income Withholding
Check here if all parties agree not to have the employer withhold child support payments at thi s time.
The parties agree, and the Court ORDERS that an income withholding for support order shall not be
served on the employer unless: 1) child support payments are more than 30 days late, 2) the past d ue
amount is the same or more than the monthly child support amount, 3) another violation of this child
support order occurs or 4) the Office of the Attorney General Child Support Division is provid ing services
to Obligee . Obligor is ORDERED to send all child support payments to the Texas Child Support
Disbursement Unit, PO Box 659791, San Antonio, TX 78265
, where the payment will be recorded, and
forwarded to Obligee.
9K. Change of Employment
Obligor is ORDERED to notify this Court and Obligee by U.S. certified mail, return receipt requested, of
any change of address and of any termination of employment. This notice shall be given no later than 7
days after the change of address or the termination of employment. This notice or a subsequent noti ce
shall also provide the current address of Obligor and the name and address of Obligor’s current employer,
whenever that information becomes available.
9L. Child Support After Death
IT IS ORDERED that the provisions for child support in this decree shall be an obligation of Obligor’s
estate and shall not terminate on his/her death. Payments received for the benefit of the child /ren,
including payments from the Social Security Administration, Department of Veterans Aff airs, or other
governmental agency or life insurance proceeds, annuity payments, trust distributions , or retirement
survivor benefits, shall be a credit against this obligation. Any remaining balance o f the child support is an
obligation of Obligor ’s estate.
9M. Life Insurance Policy
Check here if the person ordered to pay child support should also be ordered to maintain a life ins urance policy for as
long as child support is ordered.
As additional child support, the person paying child support under this order is ORDERED to obtain
and maintain a life insurance policy on his or her life for as long as child support is ordered. The v alue of
the policy shall be at least as much as the total child support obligation. The person receiving child
support under this order must be named as the primary beneficiary for the benefit of the children.
NOTICE REGARDING MODIFYING (CHANGING) THIS CHILD SUPPORT ORDER
THE COURT MAY MODIFY THIS ORDER THAT PROVIDES FOR THE SUPPORT OF A CHILD, IF: (1)THE CIRCUMSTANCES OF THE CHILD OR A PERSON AFFECTED BY THE ORDER HAVE
MATERIALLY OR SUBSTANTIALLY CHANGED; OR
(2)IT HAS BEEN THREE YEARS SINCE THE ORDER WAS RENDERED OR LAST MODIFIED AND
THE MONTHLY AMOUNT OF THE CHILD SUPPORT AW ARD UNDER THE ORDER DIFFERS BY
EITHER 20 PERCENT OR $100 FROM THE AMOUNT THAT WOULD BE AWARDED IN
ACCORDANCE WITH THE CHILD SUPPORT GUIDELINES.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
10
. Medical Support
10 A. Parents’ Obligation to Provide Medical Support
As additional child support, the Court ORDERS the parents to provide medical support as set out in this
order for each child listed in 5A above until one of the following events that terminate medical support
occurs for the child.
10 B. Events that Terminate Medical Support
The obligation to provide medical support for a child terminates when:
● The child turns 18, unless when the child turns 18 he or she is enrolled and complying with
attendance requirements in a secondary school program leading toward a high school diploma or
enrolled in courses for joint high school and junior college credit then child support terminates at
the end of the month in which the child graduates. -or -
● The child marries, dies, or is emancipated by court order. -or -
● The child begins active duty in the United States armed forces. -or -
● A court terminates the parent -child relationship between the man ordered to pay child support and
the child based on genetic testing that determines the man is not the child’s father. -or -
● The person ordered to pay child support and the person ordered to receive child support marry or
remarry each other, unless a nonparent or agency has been appointed conservator of the child.
10 C. Court Findings about Health Insurance
The Court finds that private health insurance for the children:
(Check one.)
is available at a reasonable cost to the person ordered to pay child support (Obligor) through:
(Check one.)
Father’s work, membership in a union, trade association, or other organization, or other
source available to Father.
Mother’s work, membership in a union, trade association, or other organization, or other
source available to Mother.
is not available at a reasonable cost to either parent. The Court finds that the children are:
(Check one.)
currently covered by Medicaid.
currently covered by C.H.I.P. at this cost : $ __________________.
not currently covered by Medicaid or C.H.I.P.
10D. Orders Regarding Health Insurance and Cash Medical Support
Check box 10D(1), 10 D(2) , OR 10 D(3) on the following pages and write in the appropriate names (and start date if
cash medical support is ordered) .
Note: The Obligor is the parent ordered in this decree to pay child support and the Obligee is the parent who
will receive child support .
● Check box 10 D(1) if the Obligor will provide and pay for health insurance for the children .
● Check box 10D(2) if the Obligee will provide health insurance for the children and the Obligor will pay cash
medical support to reimburse the Obligee for the cost of the insurance .
● Check box 10D(3) if neither parent has access to private health insurance at a reasonable cost . Obligee will be
ordered to apply for coverage under a government medical assistance program and Obligor will be ordered to
pay cash medical support.
Page 13 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
10
D(1)
Obligor to Provide and Pay for Health Insurance
As additional child support, the Court ORDERS Obligor, ___________________________________,
(Print name of parent ordered to pay child support)
to get health insurance for the child/ren within 15 days of the date of this order through: (Check one.)
Obligor’s work or membership in a union, trade association, or other organization.
another source available to Obligor.
The health insurance must cover basic healthcare services, including usual physician services , office
visits, hospitalization, and laboratory, X -ray, and emergency services.
Obligor is ORDERED to pay, as additional child support, all costs of such health i nsurance, including
but not limited to enrollment fees and premiums.
Obligor is ORDERED to keep such health insurance in full force and effect on each ch ild, who is the
subject of this suit, until one of the above events that terminate medical support occurs for the
child.
Obligor is ORDERED to give Obligee the following within 30 days of the date of this order:
o Obligor’s social security number and the name and address of Obligor’s employer, and
o the name of the insurance carrier, the policy number, and proof the child/ren are covered, and
o a copy of the insurance policy and list of benefits covered, and
o insurance membership cards for the child/ren, and
o any forms needed to use the health insurance, and
o any forms needed to submit a claim.
Obligor is ORDERED to give Obligee the following within 3 days of receipt:
o any insurance checks or other payments for medical expenses paid by Obligee and
o any explanatio ns of benefits relating to medical expenses paid or incurred by Obligee .
If health insurance benefits for the child/ren are changed
in any way, Obligor is ORDERED to give
Obligee information about the change and any new forms needed to use the insurance within 15
days of the change.
If health insurance benefits are cancelled, Obligor is ORDERED to get new health insurance for the
children within 15 days of the date of cancellation. The new insurance must equal or exceed the
prior level of coverage. The new health insurance must cover basic healthcare services, including
usual physician services, office visits, hospitalization, and laboratory, X -ray, and emergency services.
If Obligor is eligible for dependent health coverage but fails to apply to obtain cover age for the
child/ren, the insurer is ORDERED to enroll the child/ren on application of Obligee or ot hers as
authorized by law. See Texas Insurance Code, Section 1504.051
Page 14 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
10
D(2)
Obligee to Provide Health Insurance / Obligor to Reimburse Cost
As additional child support, the Court ORDERS Obligee, __________ ______ ___ _______________,
(Print name of parent who will receive child support)
to get health insurance for the child/ren within 15 days of the date of this order through: (Check one.)
Obligee’s work or membership in a union, trade association, or other organization.
another source available to Obligee.
The health insurance must cover basic healthcare services, including usual physician services , office
visits, hospitalization, and laboratory, X -ray, and emergency services.
Obligee is ORDERED to maintain such health insurance in full force and effect on each child until one
of the above events that terminate medical support occurs for the child.
Obligee is ORDERED to give Obligor the following within 30 days of the date of this orde r:
o Obligee’s social security number and the name and address of Obligee’s employer, a nd
o the name of the insurance carrier, the policy number, and proof the child/ren are covered, and
o the name of the insurance company and the policy number, and
o a copy of the insurance policy and list of benefits covered, and
o insurance membership cards for the child/ren, and
o any forms needed to use the health insurance, and
o any forms needed to submit a claim.
Obligee is ORDERED to give Obligor the following within 3 days of receipt:
o any insurance checks or other payments for medical expenses paid by Obligor and
o any explanations of benefits relating to medical expenses paid or incurred by Obligor.
If health insurance benefits for the child/ren are changed
in any way, Obligee is ORDERED to give
Obligor information about the change and any new forms needed to use the insurance within 15
days of the change. If the cost
of health insurance benefits for the child/ren changes, Obligee is
ORDERED to give Obligor information about the change within 15 days of the change.
If health insurance benefits are cancelled, Obligee is ORDERED to get new health insurance for the
children within 15 days of the date of cancellation. The new insurance must equal or exceed the
prior level of coverage. The new health insurance must cover basic healthcare services, includ ing
usual physician services, office visits, hospitalization, and laboratory, X -ray, and emergency services.
If Obligee is eligible for dependent health coverage but fails to apply to obtain coverage for t he
child/ren, the insurer is ORDERED to enroll the child/ren on application of Obligor or ot hers as
authorized by law. See Texas Insurance
Code, Section 1504.051
As additional child support, the Court ORDERS Obligor, __________________________________,
( Print n ame of parent ordered to pay child support)
to pay Obligee cash medical support of $ ______________ per month for reimbursement of health
insurance premiums. The 1 st
payment is due on ______________________ . A like payment is
Month / Day / Year
due on the 1 st
day of each month after that until one of the above events that terminate medical
support occurs for each child.
Obligor is ORDERED to send all cash medical support payments to the Texas Child Support
Disbursement Unit, PO Box 659791, San Antonio, TX 78265 for distribution according to law.
The Court ORDERS that money paid by Obligor directly to Obligee or spent while in poss ession of
the children does NOT count as cash medical support.
The Court ORDERS that the cash medical support provisions of this order shall be an obligat ion of
the estate of Obligor and shall not terminate on his/her death.
Warning! Do not
pay cash medical support directly to the other parent. Send all payments to the
Texas Child Support Disbursement Unit, PO Box 659791, San Antonio, TX 78265.
Page 15 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
10
D(3)
Obligee to App ly for Coverage under a Government Medical Assistance
Program or Health Plan / Obligor to Pay Cash Medical Support
The Court ORDERS Obligee, _______________________________________, to apply on behalf of
(Print name of p arent who will receive child support)
each child for coverage under a governmental medical assistance program or health plan (i.e.
Medicaid or C.H.I.P) within 15 day s of the date this decree or order is signed by the Court. If the
children are already covered under such a program or plan, the Court ORDERS Obligee to continue
such coverage.
When such health coverage is obtained, O bligee is ORDERED to maintain the coverage in full force
and effect on each child by paying all applicable fees required for the coverage, including but not
limited to enrollment fees and premiums for as long as the children are eligible for such coverage.
Obligee is ORDERED to give the Office of the Attorney General Child Support Division a c opy of the
insurance policy and list of benefits covered within 30 days of the date of this order.
Obligee is ORDERED to give Obligor the following within 30 days of the date of this order:
o the name of the insurance company and the policy number, and
o a copy of the insurance policy and list of benefits covered, and
o insurance membership cards for the child/ren, and
o any forms needed to use the health insurance, and
o any forms needed to submit a claim.
Obligee is ORDERED to give Obligor the following within 3 days of receipt:
o any insurance checks or other payments for medical expenses paid by Obligor and
o any explanations of benefits relating to medical expenses paid or incurred by Obligor.
If Obligee is eligible for dependent health coverage but fails to apply to obtain coverage for t he
child/ren, the insurer is ORDERED to enroll the child/ren on application of Obligor or ot hers as
authorized by law. Texas Insurance Code, Sectio
n 1504.051
As additional child support, the Court ORDERS Obligor, __________________________________,
(Print name of parent ordered to pay child support)
to pay Obligee cash medical support of $ _________ _______ per month. The 1 st
payment is due
on _____________________ _. A like payment is due on the 1 st
day of each month after that until
Month / Day / Year
one of the above events that terminate medical support occurs for each child.
The Court ORDERS Obligor to send all cash medical support payments to the Texas Child Support
Disbursement Unit, PO Box 659791, San Antonio, TX 7826 5 for distribution according to law.
Warning! Do not pay cash medical support directly to the other parent. Send all payments to the
Texas Child Support Disbursement Unit, PO Box 659791, San Antonio, TX 78265.
The Court ORDERS that money paid by Obligor directly to Obligee or spent while in poss ession of
the children does NOT count as cash medical support.
IT IS ORDERED that Obligor is allowed to stop paying of cash medical support, for the time
Obligor is providing health insurance coverage for the children, if:
a . health insurance for the children becomes available to Obligor at a reasonable cost; and
b . Obligor enrolls the child/ren in the insurance plan and pays all costs of the insurance; and
c. Obligor provides Obligee and the Texas Office of the Attorney General, Child Support
Division the following information:
(1)proof that health insurance has been provided for the child/ren, and
(2) Obligor’s social security number, and
(3) name and address of the Obligor’s employer, and
(4) whether the employer is self -insured or has health insurance available, and
Page 16 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
(4
i) if the employer is self -insured, a copy of the schedule of benefits, a membership
card, claim forms, and any other information necessary to submit a claim, or
(4 ii) if the employer has health insurance available, the name of the health insurance
carrier, the policy number, a copy of the policy and schedule of benefits, a health
insurance membership card, claim forms, and any other information necessary to
submit a claim.
Note: This provision regarding when the Obligor may stop paying cash medical support is part of s ection
10D3 . It does not apply to any other section.
10E. Expenses Not Covered by Insurance
Obligor and Obligee are each ORDERED to pay 50 percent of all reasonable and necessary health -care
expenses for the child/ren that are not covered by health insurance , unless:
10 D(1) above is checked and Obligor is not
providing health insurance as ordered , then Obligor is
liable for 100 percent of all necessary medical expenses of the child/ren.
10 D(2) above is checked and Obligee is not providing health insurance as ordered , then Obligee is
liable for 100 percent of all necessary medical expenses of the c hild/ren.
If 10 D(3) above is checked, Obligee is ORDERED to pay 50 percent of all reasonable and necessary
health -care expenses for the child/ren that are not reimbursed by health insurance or covered by the cash
medical support paid by Obligor and Obligor is ORDERED to pay 50 percent of the total unreimbursed
health -care expenses that exceed the amount of cash medical support paid by Obligor. Obligor is liable
for 100 percent of all necessary medical expenses incurred for the child/ren in any month that Ob ligor
neither pays cash medical support nor provides health insurance for the child/ren.
Reasonable and necessary health care expenses that must be paid by the parents if not covered
by insurance include : copayments for office visits and prescription drugs, the yearly deductible, if any,
medical, surgical, and prescription drug expenses, mental health -care services, dental and orthodontic
expenses, and eye care and ophthalmological expenses. These reasonable and necessary health -care
expenses do not include expenses for travel to and from the health -care provider or for nonprescription
medication.
The parent who incurs a health -care expense on behalf of a child (called the “incurring parent”) is
ORDERED to give the other parent (called the “nonincurring parent”) a copy of all forms, receipts, bills,
statements, and explanations of benefits that show the portion of the expense not covered by insurance
within 30 days of receipt. The nonincurring parent is ORDERED to pay his or her percentage of any
unins ured expense within 30 days of receiving documentation of the expense by paying the health -care
provider directly or reimbursing the incurring parent, if the nonincurring parent’s portion has already been
paid.
10 F. Claims
Either parent may file claims and receive payments directly from the insurance carr ier. Further, for the
sole purpose of Texas Insurance Code Sections 1204.251 and 1204.252 , the party who is not carrying
the insurance policy is designated the managing conservator or possessory conservator of the children.
Any reimbursement payments received from the health insurance carrier belong s to the parent who paid
the expense. If the insurance carrier sends reimbursement to the parent who did not
pay the expense, he
or she is ORDERED to endorse the check and deliver it to the parent who paid the expense with 3 days.
10 G. Health Insurance Policy Requirements
Each parent is ORDERED to follow all requirements of any health insurance policy covering the chi ld/ren
to get maximum reimbursement and direct payment from the insurance company. This includes
requirements for giving advance notice to the insurance company, getting second opinions, and using
“preferred providers .” If a parent incurs health -care expenses for the child/ren using “out -of -network”
health -care providers or services, or fails to follow the health insurance company procedures or
requirements, that parent shall pay all such health -care expenses incurred unless: the expenses are
emergency health -care expenses , the parents have a written agreement regarding such health -care
expenses, or the Court makes a different order. Denial of a bill by a n insurance c arrier does not excuse
the obligation of the parent s to pay the expense.
Page 17 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
11 .
Parent’s Information
11 A. Disclosure of Mother’s Information
(Check one box.)
The Court ORDERS Mother to disclose the following information and changes in that information to
Father, the Court and the State Case Registry as required by Te x as Family Code 105.006 and
ORDERED in section 12 of this Decree.
( Fill in the following information for the Wife/Mother.)
Name:
Home Address:
Mailing Address:
Home phone # ( ) Work phone #: ( )
FULL Social Security #: ___ ___ ___ --___ ___ --___ ___ ___ ___
Driver’s License #: Issuing state:
Employer:
Work address:
The Court finds, pursuant to Texas Family Code 105.006(c) and 105.007(c) , that disclosure of
Mother ’s information to Father is likely to cause Mother or the children harassment, abuse, serious
ha rm or injury or would subject Mother or the children to family violence . The Court ORDERS that
Mother ’s address and other identifying information not be disclosed. The Court further ORDERS that
Mother is not required to give her address or other identifying information to Father or notify Father o r
the Court of changes in that information. The Court ORDERS Mother to provide her mailing address
and changes in her mailing address to the State Case Registry, Contract Services Se ction, MC046S,
P.O. Box 12017, Austin, Texas 78711 -2017.
11 B. Disclosure of Father’s Information (Check one box.)
The Court ORDERS Father to disclose the following information and changes in that information to
Mo ther, the Court and the State Case Registry as required by
Texas Family Code 105.006 and
ORDERED in section 12 of this Decree.
( Fill in the following information for the Husband/Fath er.)
Name:
Home Address:
Mailing Address:
Home phone #: ( ) Work phone #: ( )
FULL Social Security #: ___ ___ ___ --___ ___ --___ ___ ___ ___
Driver’s License #: Issuing state:
Employer:
Work address:
The Court finds , pursuant to Texas Family Code Section 105.006(c) and 105.007(c), that disclosure of
Father’s information to Mother is likely to cause Father or the children harassment, abuse, serio us
harm or injury or would subject Father or the children to family violence . The Court ORDERS that
Father’s address and other identifying information not be disclosed. The Court further ORDERS that
Father is not required to give his address or other identifying information to Mother or notify Mother or
the Court of changes in that information. The Court ORDERS Father to provide his mailing addres s
and changes in his mailing address to the State Case Registry, Contract Services Section, MC046S,
P. O. Box 12017, Austin, Texas 78711 -2017.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
12.
Required Notices
This section is not applicable if and to the extent it conflicts with the C ourt’s Order regarding
disclosure of information in section 11 above.
EACH PERSON W HO IS A PARTY TO THIS ORDER IS ORDERED TO NOTIFY EVERY OTH ER PARTY,
THE COURT, AND THE STATE CHILD SUPPORT REGISTRY OF ANY CHANGE IN THE PART Y’S:
• CURRENT RESIDENCE ADDRESS,
• MAILING ADDRESS,
• HOME TELEPHONE NUMBER,
• NAME OF EMPLOYER,
• ADDRESS OF EMPLOYMENT,
• DRIVER’S LICENSE NUMBER, AND
• WORK TELEPHONE NUMBER.
THE PARTY IS ORDERED TO GIVE NOTICE OF AN INTENDED CHANGE IN ANY OF THE REQUIRED
INFORMATION TO THE OTHER PARTY, THE COURT, AND THE STATE CASE REGISTRY ON OR
BEFORE THE 60 TH
DAY BEFORE THE INTENDED CHANGE. IF THE PARTY DOES NOT KNOW OR
C OULD NOT HAVE KNOWN OF THE CHANGE IN SUFFICIENT TIME TO GIVE NOTICE OF THE
CHANGE TO PROVIDE 60 -DAYS NOTICE, THE PARTY IS ORDERED TO GIVE NOTICE OF THE
CHANGE ON OR BEFORE THE 5 TH
DAY AFTER THE DATE THAT THE PARTY KNOWS OF THE
CHANGE.
THE DUTY TO FURNISH THIS INFORMATION TO EVERY OTHER PARTY, THE COURT, AND T HE
STATE CASE REGISTRY CONTINUES AS LONG AS ANY PERSON, BY VIRTUE OF THIS ORD ER, IS
UNDER AN OBLIGATION TO PAY CHILD SUPPORT OR ENTITLED TO POSSESSION OF OR ACCESS
TO A CHILD.
FAILURE BY A PARTY TO OBE Y THE ORDER OF THIS COURT TO PROVIDE EVERY OTHER PARTY,
THE COURT, AND THE STATE CASE REGISTRY WITH THE CHANGE IN THE REQUIRED
INFORMATION MAY RESULT IN FURTHER LITIGATION TO ENFORCE THE ORDER, INCLUDING
CONTEMPT OF COURT. A FINDING OF CONTEMPT MAY BE PUNISHABLE BY CONFINEMENT I N
JAIL FOR UP TO SIX MONTHS, A FINE OF UP TO $500 FOR EACH VIOLATION AND A MONEY
JUDGMENT FOR PAYMENT OF ATTORNEY’S FEES AND COURT COSTS.
Notice shall be given to every other party by delivering a copy of the notice to each party by registered
or certified mail, return receipt requested.
Notice shall be given to the Court by delivering a copy of the notice either in person to the clerk of the
C ourt or by registered or certified mail addressed to the clerk.
Notice shall be given to t he State Case Registry by mailing a copy of the notice to the State Case
Registry, Contract Services Section, MC046S, P.O. Box 12017, Austin, Texas 78711-2017.
13 . Warnings to Parties
FAILURE TO OBEY A COURT ORDER FOR CHILD SUPPORT OR FOR POSSESSION OF O R
ACCESS TO A CHILD MAY RESULT IN FURTHER LITIGATION TO ENFORCE THIS ORDER,
INCLUDING CONTEMPT OF COURT. A FINDING OF CONTEMPT MAY BE PUNISHABLE BY
CONFINEMENT IN JAIL FOR UP TO SIX MONTHS, A FINE OF UP TO $500 FOR EACH VIOLA TION
AND A MONEY JUDGMENT FOR PAYMENT OF ATTORNEY’S FEES AND COURT COSTS.
FAILURE OF A PARTY TO MAKE A CHILD SUPPORT PAYMENT TO THE PLACE AND IN THE
MANNER REQUIRED BY A COURT ORDER MAY RESULT IN THE PARTY’S NOT RECEIVING CR EDIT
FOR MAKING THE PAYMENT.
FAILURE OF A PARTY TO PAY CHILD S UPPORT DOES NOT JUSTIFY DENYING THAT PARTY
COURT -ORDERED POSSESSION OF OR ACCESS TO A CHILD. REFUSAL BY A PARTY TO ALLO W
POSSESSION OF OR ACCESS TO A CHILD DOES NOT JUSTIFY FAILURE TO PAY COUR T-
ORDERED CHILD SUPPORT TO THAT PARTY.
Page 19 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
14
. Property and Debt
The Court finds that the following is a just and right division of the parties’ property and debt .
(Fill in all lines. If there is no property to declare in a particular category, wr ite “none”.)
14A . Husband’s Separate Property
The Court confirms that the Husband owns the following property as his separate property:
1. House or Land located at:
__________________________________________________________ Street Address City State Zip
Husband owned this property before marriage.
Husband received this property as a gift or inheritance.
2. Cars, truck s, motorcycles or other vehicles Husband owned these vehicles before marriage or
received them as a gift or inheritance during the marriage:
Year Make Model Vehicle Identification No. [VIN]
3.Other Money or Property Confirmed as Husband’s Separate Property
Husband owned the following money or property before the marriage or
inherited or received the
money or property as a gift during the marriage:
Husband received the following money recovery for personal injuries that occurred during the
marriage that is not for lost wages or medical expenses:
14B. Husband’s Community Property
The Court ORDERS that the Husband is awarded the following community property as his sole and
separate property and W ife is divested of (loses ) a ll right , title, interest and claim in and to that property.
Wife is ORDERED to sign any deeds or documents needed to transfer any property listed be low to the
Husband. Husband is responsible for preparing the documents .
1. A ll property in Husband’s care, custody or control, or in Husband’s name, that this Decree does not
give to the W ife.
2. House or land located at:
Street Address City State Zip
Legal Description:
Note: The legal description is on the deed you received when you became an owner of the house or land. It is
also available at the county clerk’s office in the county where the house or land is located. Do NOT use the legal
description listed on your property tax bill because it is usually incomplete. IT IS VERY IMPORTANT THAT THIS
INFORMATION IS CORRECT. If you are not absolutely sure, talk to a lawyer.
3. All cash and money in any bank or other financial institution listed in Husband’s name alone.
4. Any insurance policy that covers Husband’s life.
5. Husband’s cars, trucks, motorcycles or other vehicles listed below :
Year Make Model Vehicle Identification No. [VIN]
6.Husband will also keep the following property:
Page 20 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
(Fill in all lines. If there is no property to declare in a particular category, wr
ite “none”.)
14C . Wife’s Separate Property
The Court confirms that Wife owns the following property as her separate property:
1. House or Land located at:
__________________________________________________________ Street Address City State Zip
Wife owned this property before marriage.
Wife received this property as a gift or inheritance.
2. Cars, trucks, motorcycles or other vehicles W ife owned these vehicles before marriage or
received them as a gift or inheritance during the marriage:
Year Make Model Vehicle Identification No. [VIN]
3.Other Money or Property Confirmed as Wife’s Separate Property
Wife owned the following money or personal property before the marriage:
Wife inherited or received as a gift the following money or personal property during the marriage:
Wife received the following money recovery for personal injuries that occurred during the marriage
that was not for lost wages or medical expenses:
14D. Wife ’s Community Property
The Court ORDERS that the W ife is awarded the following property as her sole and separate property
and Husband is divested of (loses ) a ll right , title, interest and claim in and to that property. Husband is
ORDERED to sign any deeds or documents needed to transfer any property listed below to the W ife .
Wife is responsible for preparing the documents .
1. All property in W ife ’s care, custody or control, or in W ife’s name, that this Decree does not give to the
Husband .
2. House or land located at:
Street Address City State Zip
Legal Description:
Note: The legal description is on the deed you received when you became an owner of the house or land. It is
also available at the county clerk’s office in the county where the house or land is located. Do NOT use the legal
description listed on your property tax bill because it is usually incomplete. IT IS VERY IMPORTANT THAT THIS
INFORMATION IS CORRECT. If you are not absolutely sure, talk to a lawyer.
3. All cash and money in any bank or other financi al institution listed in W ife’s name alone.
4. Any insu rance policy that covers Wife ’s life.
5. Wife ’s cars, trucks, motorcycles or other vehicles listed below :
Year Make Model Vehicle Identification No. [VIN]
6.Wife will also keep the following property:
Page 21 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
14
E. Retir ement Funds in Husband’s Name
(For example: pension, retirement, 401(k ), 403(b), employee stock ownership, profit sharing, thrift, Keogh, and
stock option plans , as well as individual retirement accounts (IRAs), annuities and variable annuity l ife
insurance benefits.)
The Court makes the following orders regarding retirement funds in Husband’s name .
(Check 14E(1) or 14E(2) .)
14E(1)
Husband is awarded 100% of all retirement funds in Husband’s name alone , including but not
limited to all rights to any pension, retirement, military retirement, 401(k), 403(b), employee
stock ownership, profit sharing, thrift, Keogh, and stock option plans in Husband’s name
alone, along with 100% of any individual retirement accounts (IRAs), annuities, and variable
annuity life insurance in Husband’s name alone.
14E(2)
The following retirement funds in Husband’s name are divided between Husband and Wife:
( It is very important to list the exact name and accoun t number of any retirement fund being divided by the Court .)
Formal Name of Retirement Fund Account Number
The Court ORDERS that the portion of each retirement fund listed above accrued between
the date of the marriage _____/_____ /___ ____ _ and the date this Final Decree of Divorce is
signed by the Court: (Check one.)
is awarded 50% to Husband and 50% to Wife and as more specifically described in
the Qualified Domestic Relations Order signed by the Court .
is awarded ______% to Husband and ______% to W ife and as more specifically
described in the Qualified Domestic Relations Order signed by the Court .
is awarded $ __________________ to Wife and the remainder to Husband and as
more specifically described in the
Qualified Domestic Relations Order signed by
the Court .
other:
The Court ORDERS that Husband is awarded all retirement funds in Husband’s name alone
that are not specifically awarded to Wife above.
A Qualified Domestic Relations Order was signed by the Court on the same day this
Final Decree of Divorce was signed by the Court.
The Court checks this box, if applicable.
Page 22 of 24
FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
14
F. Retirement Funds in Wife’s Name
(For example: pension, retirement, 401(k), 403(b), employee stock ownership, profit sharing, thrift, Keogh, and
stock option plans , as well as individual retirement accounts (IRAs), annuities and variable annuity l ife
insurance benefits.)
The Court makes the following orders regarding retirement funds in W ife’s name .
(Check 14F(1) or 14F(2) .)
14F(1)
Wife is awarded 100% of all retirement funds in W ife’s name alone , including all rights to any
pens ion, retirement, military retirement, 401(k), 403(b), employee stock ownership, profit
sharing, thrift, Keogh, and stock option plans in W ife ’s name alone, along with 100% of any
individual retirement accounts (IRAs), annuities, and variable annuity life insuranc e in W ife’s
name alone.
14 F(2)
The following retirement funds in W ife’s name are divided between Husband and Wife:
(It is very important to list the exact name and account number of any retirement fund being divided by the Court. )
Formal Name of Retirement Fund Account Number
The Court ORDERS that the portion of each retirement fund listed above accrued between
the date of the marriage ___ __/_____/_ _______ and the date this Final Decree of Divorce is
signed by the Court: (Check one.)
is awarded 50% to W ife and 50% to Husband and as more specifically described in
the Qualified Domestic Relations Order signed by the Court.
is awarded ______% to Wife and ______% to Husband and as more specifically
de scribed in the Qualified Domestic Relations Order signed by the Court.
is awarded $ __________________ to Husband and the remainder to Wife and as
more specifically described in the Qualified Domestic Relations Order signed by
the Court.
other:
T he Court ORDERS that Wife is awarded all retirement funds in Wife’s name alone that are
not specifically awarded to Husband above.
A Qualified Domestic Relations Order was signed by the Court on the same day this
Final Decree of Divorce was signed by the Court.
The Court checks this box, if
applicable.
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FM -DivB -201 Final Decree of D ivorce [SET B] (R ev. 01 -2016)
14
G. Debts to Husband
The Court ORDERS Husband to pay the debts listed below:
1. All debts, taxes, bills, liens, and other charges, past, present and future, that are in H usband’s name
alone unless this Decree requires otherwise.
2. Any debt Husband incurred after separation. Date of separation: ____________________________.
Month Day Year
3. The balance due on any loan or mortgage for the real propert
