NO. ____________
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§IN THE MATTER OF IN THE DISTRICT COURT
THE MARRIAGE OF
_________________
AND _______ JUDICIAL DISTRICT
_________________
AND IN THE INTEREST OF
_________________ , CHILD ____________ COUNTY, TEXAS
AGREED DECREE OF DIVORCE
On _____ ___________________________ ______ , this case came on for hearing.
1. Appearances
Petitioner, _____________ , Social Security Number ___________ , appeared in Person.
Respondent, _____________ , Social Security Number ___________ , waived issuance of
service of citation and has agreed to the terms of this Decree, as evidenced by his signature below.
2. Record
The record of testimony was duly reported by the Court Reporter.
3. Jurisdiction and Domicile
The Court finds that the pleadings of Petitioner and Respondent are in due form and contain
all the allegations, information, and prerequisites required by law. The Court, after receiving
evidence, finds that it has jurisdiction over this cause of action and the parties and that at least 60
days have elapsed since the date the suit was filed. The Court finds that Petitioner has been a
domiciliary of this state for at least a six-month period preceding the filing of this action and a
resident of the county in which this suit is filed for at least a 90-day period preceding the filing of
this action. All persons entitled to citation were properly cited.
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4. Jury
A jury was waived, and all questions of fact and of law were submitted to the Court.
5. Agreement of Parties
The parties have consented to the terms of this Decree and stipulated that the provisions
herein are contractual.
6. Divorce
IT IS ORDERED AND DECREED that _____________ , Petitioner, and _____________ ,
Respondent, are divorced and that the marriage between them is dissolved.
7. Children
The Court finds that Petitioner and Respondent are the parents of the following child:
Name: Sex:
Birthdate:
Birthplace:
Home State:
Social Security Number:
The Court finds no other children are expected.
8. Conservatorship and Support
The Court, having considered the circumstances of the parents and of the child and the
agreement of the parties, finds the following orders are in the best interest of the child.
A. Joint Managing Conservators - IT IS ORDERED AND DECREED that Petitioner,
_____________ , and Respondent, _____________ , are appointed Joint Managing Conservators of
the child.
B. Rights of Both Conservators at All Times - IT IS ORDERED AND DECREED that
_____________ and _____________ , as Joint Managing Conservators, shall each retain the right to
receive information from the other concerning the health, education, and welfare of the child and,
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to the extent possible, the right to confer with the other before making a decision concerning the
health, education, and welfare of the child.
IT IS ORDERED AND DECREED that at all times _____________ and _____________
shall each retain the following rights:
1. To have access to medical, dental, psychological, and educational records of the child;
2. To consult with any physician, dentist, or psychologist of the child;
3. To consult with school officials concerning the child's welfare and educational status,
including school activities;
4. To attend school activities;
5. The right to enroll the child in extracurricular activities, such as sports, clubs, etc.;
6. The right to participate in the child's educational activities and the right to attend parent-
teacher conferences;
7. The right to reasonable telephone access to the child when the child is in the possession
of the other party;
8. To be designated on any records as a person to be notified in case of an emergency; and
9. To manage the estate of the child to the extent the estate has been created by the parent
or the parent's family.
C. Rights of Both Conservators During Periods of Possession - IT IS ORDERED AND
DECREED that, during their respective periods of possession, _____________ and
_____________ shall retain the following rights, duties, and powers:
1. The right to physical possession and to direct the moral and religious training of the
child;
2. The duty of care, control, protection, and reasonable discipline of the child;
3. The duty to support the child, including providing the child with clothing, food, shelter,
and medical and dental care not involving an invasive procedure;
4. The power to consent to medical, dental, and surgical treatment during an emergency
involving an immediate danger to the health and safety of the child; and
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5. The right to consent to field trips, school calendar events and extracurricular activities
occurring during each Conservator's respective periods of possession.
D. Primary Joint Managing Conservator With Right to Establish Residence and Domicile
of Child - IT IS ORDERED AND DECREED that _____________ is appointed the Primary Joint
Managing Conservator and shall have the exclusive right to determine the residence and domicile
of the child.
E. Rights of Primary Joint Managing Conservator - IT IS ORDERED AND DECREED
that at all times, _____________ , as Primary Joint Managing Conservator, shall have the following
rights, duties, and powers:
1. The power to consent to medical, dental, and surgical treatment involving invasive
procedures, and to psychiatric and psychological treatment;
2. The power to represent the child in legal action and to make other decisions of
substantial legal significance concerning the child;
3. The power to consent to marriage and to enlistment in the Armed Forces of the United
States;
4. The right to the services and earnings of the child;
5. Except when a guardian of the child's estate or a guardian or attorney ad litem has been
appointed for the child, the power as an agent of the child to act in relation to the
child's estate if the child's action is required by a state, the United States, or a foreign
government;
6. The right to make educational decisions on behalf of the child; and
7. The right to manage the estate of the child to the extent the estate has been created by
community property or the joint property of the parents.
F. Rights of Other Joint Managing Conservator - IT IS ORDERED AND DECREED that
at all times _____________ , as Joint Managing Conservator, shall have the following rights, duties,
and powers:
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1. The power to represent the child in legal action and to make other decisions of
substantial legal significance concerning the child;
2. The power to consent to marriage and to enlistment in the Armed Forces of the United
States;
3. The right to the services and earnings of the child;
4. Except when a guardian of the child's estate or a guardian or attorney ad litem has been
appointed for the child, the power as an agent of the child to act in relation to the
child's estate if the child's action is required by a state, the United States, or a foreign
government;
5. The right to make educational decisions on behalf of the child; and
6. The right to manage the estate of the child to the extent the estate has been created by
community property or the joint property of the parents.
G. Possession Schedule - IT IS ORDERED AND DECREED that _____________ shall
have possession of the child during alternate weeks from 6:00 p.m. on Sunday until the
immediately following Sunday at 6:00 p.m.
IT IS ORDERED AND -DECREED that _____________ shall have possession of the child
during alternate weeks from 6:00 p.m. on Sunday until the immediately following Sunday at 6:00
p.m.
(a) Specific Provision for Children are 15 and Over - Upon a minor child reaching the
age of fifteen (15) years, all of the above set forth visitation shall cease as mandatory
visitation, and, in lieu thereof, such child shall visit with the Petitioner or
Respondent at such times as are set forth above or as are agreeable both between
such child and Petitioner and Respondent.
(b) Minimizing Disruptions - IT IS ORDERED AND DECREED that each party shall
have due consideration regarding their periods of possession with the child so as to
minimize disruption of the child's schooling, daily routine, and association with
friends and family of the parties hereto. Each party is ORDERED to make every
effort to avoid scheduling activities for the child during the other party's periods of
possession unless the other party has been consulted and an agreement reached.
(c) Telephone Communication/Access - IT IS ORDERED AND DECREED that each
party shall have the right to have private reasonable telephone access to, and
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communication with, the child during the other party's periods of possession, such
access and communication not to be unreasonably withheld.
(d) Emergency Phone Number Exchange - In the event either party is to be absent with
the minor child from their respective residences for an overnight period or longer,
the party planning such absence is ORDERED to furnish the other party information
as to an emergency phone number where the party can be contacted. This
information may be conveyed to the other party's answering machine.
(e) Medical Emergency - IT IS ORDERED AND DECREED that each party is to
inform the other party within six (6) hours of any medical condition of the parties'
child requiring surgical intervention and/or hospitalization.
(f) Right of First Refusal - IT IS ORDERED AND DECREED that if either parent is to
be absent from the child during their periods of possession for an overnight period,
or longer, then, in that event, the parent planning such absence is ORDERED to
notify the other parent of such absence. Thereafter, it is ORDERED AND
DECREED that the parent remaining shall have the option to have possession of the
child during the absence of the other parent.
(g) Notification of Change In Required Information - WARNING: EACH PARTY
WHO IS A PARTY TO THIS ORDER IS ORDERED TO NOTIFY EACH OTHER
PARTY WITHIN 10 DAYS AFTER THE DATE OF ANY CHANGE IN THE
PARTY'S CURRENT RESIDENCE ADDRESS, MAILING ADDRESS, HOME
TELEPHONE NUMBER, NAME OF EMPLOYER, ADDRESS OF
EMPLOYMENT, AND WORK TELEPHONE NUMBER. THE PARTY IS
ORDERED TO GIVE NOTICE OF AN INTENDED CHANGE IN ANY OF THE
REQUIRED INFORMATION TO EACH OTHER PARTY ON OR BEFORE THE
60TH DAY BEFORE THE INTENDED CHANGE. IF THE PARTY DOES NOT
KNOW QR COULD NOT HAVE KNOWN OF THE CHANGE IN SUFFICIENT
TIME TO PROVIDE 60 DAY NOTICE, THE PARTY IS ORDERED TO GIVE
NOTICE OF THE CHANGE ON OR BEFORE THE FIFTH DAY AFTER THE
DATE THAT THE PARTY KNOWS OF THE CHANGE.
THE DUTY TO FURNISH THIS INFORMATION TO EACH OTHER PARTY
CONTINUES AS LONG AS ANY PERSON, BY VIRTUE OF THIS ORDER, IS
UNDER AN OBLIGATION TO PAY CHILD SUPPORT OR ENTITLED TO
POSSESSION OF OR ACCESS TO A CHILD.
FAILURE BY A PARTY TO OBEY THE ORDER OF THIS COURT TO
PROVIDE EACH OTHER PARTY 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 PUNISHED BY CONFINEMENT IN JAIL FOR UP TO
SIX MONTHS, A FINE OF UP TO $500 FOR EACH VIOLATION, AND A
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MONEY JUDGMENT FOR PAYMENT OF ATTORNEY'S FEES AND COURT
COSTS.
Notice must be given to each other party in writing by registered or certified mail,
return receipt requested, to the party's last known address.
H. Child Support - IT IS ORDERED AND DECREED that no child support shall be
payable by either party to the other party.
WARNING: FAILURE TO OBEY A COURT ORDER FOR CHILD SUPPORT OR FOR
POSSESSION OF OR ACCESS TO A CHILD MAY RESULT IN FURTHER LITIGATION TO
ENFORCE THE 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 $500.00 FOR EACH VIOLATION, AND A MONEY JUDGMENT FOR PAYMENT OF
ATTORNEY'S FEES AND COURT COSTS.
WARNING: 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 NOT RECEIVING CREDIT FOR MAKING THE PAYMENT.
WARNING: FAILURE OF A PARTY TO PAY CHILD SUPPORT DOES NOT JUSTIFY
DENYING THAT PARTY COURTÄORDERED POSSESSION OF OR ACCESS TO A CHILD.
REFUSAL BY A PARTY TO ALLOW POSSESSION OF OR ACCESS TO A CHILD DOES
NOT JUSTIFY FAILURE TO PAY COURT-ORDERED CHILD SUPPORT TO THAT PARTY.
I. Health Insurance For Child - IT IS ORDERED AND DECREED that _____________
shall, at all times, provide and pay for health insurance for the child. IT IS FURTHER ORDERED
AND DECREED that within 14 days after this Decree of Divorce is signed, _____________ shall
furnish to _____________ a true and correct copy of the health insurance policy or certificate and a
schedule of benefits covering the child. IT IS FURTHER ORDERED AND DECREED that
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_____________ shall furnish to _____________ a true and correct copy of any renewals or
changes (including conversions) of the insurance policy within 14 days after the issuance of the
renewal or change.
IT IS ORDERED AND DECREED that _____________ submit to _____________ any and
all forms, receipts, bills, and statements reflecting the medical or health care expenses
_____________ incurs on behalf of the child within ten (10) days of receiving them.
IT IS ORDERED AND DECREED that _____________ submit all forms required by the
insurance company for payment or reimbursement of medical or health care expenses incurred by
either party on behalf of the child to the insurance carrier within ten (10) days of his receiving any
form, receipt, bill, or statement reflecting the expenses.
IT IS ORDERED AND DECREED that any insurance payments received by
_____________ as reimbursement for health care expenses incurred by or on behalf of the child
shall belong to the party who incurred and paid those expenses. IT IS FURTHER ORDERED AND
DECREED that _____________ is designated a constructive trustee to receive any insurance
checks or payments for expenses incurred and paid by the other party, and _____________ shall
endorse and forward the checks or payments, along with any explanation of benefits, to the other
party within ten (10) days of receiving them.
Each party is ORDERED AND DECREED to pay 50% of all health care expenses not paid
by insurance and incurred by or on behalf of the parties' child, including, without limitation, the
yearly deductible and medical, prescription drug, psychiatric, psychological, dental, eye care,
ophthalmological, and orthodontic charges, until the child attains the age of 18 years or graduates
from high school or is otherwise emancipated. IT IS FURTHER ORDERED AND DECREED that
_____________ shall submit to _____________ any and all forms, receipts, bills, and statements
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reflecting the uninsured portion of the medical or health care expenses the paying party incurs on
behalf of the child within ten (10) days after he or she receives them.
IT IS ORDERED AND DECREED that, within ten (10) days after the nonpaying party
receives the forms, receipts, bills, or statements, that party shall pay his or her 50% share of the
uninsured portion of the medical or health care expenses either by paying the health care provider
directly or by reimbursing the paying party for any advance payment over and above the paying
party's share of the expenses.
This provision shall not be interpreted to include expenses for psychological testing, travel
to and from the health care provider, or nonprescription medication.
IT IS ORDERED AND DECREED that reasonableness of the charges for medical expenses
shall be presumed on presentation of the bill to a party and that disallowance of the bill by a health
insurer shall not excuse that party's obligation to make payment or reimbursement as otherwise
provided herein.
IT IS ORDERED AND DECREED that all bills, invoices, statements, claims, explanations
of benefits, insurance policies, medical insurance identification cards, other documents, and written
notices, as well as payments, required to be transmitted by one party to the other under the health
ca-re coverage and health insurance provisions of this decree shall be transmitted by the sending
party to the residence of the receiving party.
WARNING: ANY OBLIGOR WHO FAILS TO PROVIDE HEALTH INSURANCE AS
ORDERED IS LIABLE FOR ANY NECESSARY MEDICAL EXPENSES OF THE CHILD,
WITHOUT REGARD TO WHETHER THE EXPENSES WOULD HAVE BEEN PAID BY
HEALTH INSURANCE HAD IT BEEN PROVIDED.
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9. Division of Marital Property
The Court finds that the following is a just and right division of the parties' marital estate,
having due regard for the rights of each party. The Court finds that the parties have stipulated that
the provisions of this Decree relating to the division of the marital estate is contractual and their
respective signatures -appearing below are a further reflection of this stipulation.
IT IS ORDERED AND DECREED that the estate of the parties is divided as follows:
A. Property to Petitioner - Petitioner is awarded the following as Petitioner's sole and
separate property, and Respondent is divested of all right title, interest, and claim in and to such
property:
1. A one-half undivided interest in and to the following real property including, but not
limited to, any escrow funds and prepaid insurance: _____________________ .
2. The following items of household furniture, _____________________________ .
3. All clothing, jewelry, and other personal effects in the possession of or subject to the
sole control of Petitioner.
4. Any and all sums of cash in the possession of or subject to the sole control of Petitioner,
including money on account in banks, savings institutions, or other financial
institutions, which account stand in Petitioner’s sole name or from which Petitioner
has the sole right to withdraw funds or which are subject to Petitioner’s sole control.
5. Any and all sums, whether matured or unmatured, accrued or unaccrued, vested or
otherwise, together with all increases thereof, the proceeds therefrom, and any other
rights related to any profit-sharing plan, retirement plan, pension plan, employee
stock option plan, employee savings plan, accrued unpaid bonuses, defined
contribution plans, or other benefit program existing by reason of Petitioner's past,
present, or future employment, including Petitioner's employment with
_____________ .
6. The sum of $ _____________ from Respondent's Defined Contribution Plans with
_____________ , unadjusted for any allocable gains or losses.
7. Any and all policies of life insurance (including cash values) insuring the life of
Petitioner.
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8. The _____________ motor vehicle, Vehicle Identification Number _____________ ,
together with all prepaid insurance, keys, and title documents.
B. Property to Respondent - Respondent is awarded the following as Respondent's sole and
separate property, and Petitioner is divested of all right, title, interest, and claim in and to such
property:
1. A one-half undivided interest in and to the following real property including, but not
limited to, any -escrow funds and prepaid insurance: _____________________ .
2. The following items of household furniture, _____________________________ .
3. All clothing, jewelry, and other personal effects in the possession of or subject to the
sole control of Respondent.
4. Any and all sums of cash in the -possession of or subject to the sole control of
Respondent, including money on account in banks, savings institutions, or other
financial institutions, which accounts stand in Respondent's sole name or from
which Respondent has the sole right to withdraw funds or which are subject to
Respondent's sole control.
5. Any and all sums, whether matured or unmatured, accrued or unaccrued, vested or
otherwise, together with all increases thereof, the proceeds therefrom, and any other
rights related to any profit-sharing plan, retirement plan, pension plan, employee
stock option plan, employee savings plan, accrued unpaid bonuses, or other benefit
program existing by reason of Respondent's past, present, or future employment,
with the exception of the amount awarded to Petitioner from Respondent's Defined
Contribution Plans with _____________ as set out in No. 6 above.
6. Any and all policies of life insurance (including cash values) insuring the life of
Respondent.
7. The _____________ , Vehicle Identification Number _____________ , together with all
prepaid insurance, keys, and title documents.
8. The _____________ motor vehicle, Vehicle Identification Number _____________ ,
together with all prepaid insurance, keys, and title documents.
C. Debts to Petitioner - IT IS ORDERED AND DECREED that Petitioner shall pay, as a
part of the division of the estate of the parties, the following and shall indemnify and hold
Respondent and Respondent's property harmless from any failure to so discharge these items:
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1. The balance due and owing to _____________ , Account No. _____________ , and
secured by the _____________ automobile awarded to Petitioner herein.
2. One-half of the balance due and owing on the _____________ card in both parties'
names.
3. One-half of the balance due and owing on the _____________ card in both parties'
names.
4. One-half of the balance due and owing on the _____________ Card in both parties'
names.
5. All encumbrances, ad valorem taxes, liens, assessments, or other charges due or to
become due on the real and –personal property awarded to Petitioner in this Decree
unless express provision is made herein to the contrary.
D. Debts to Respondent - IT IS ORDERED AND DECREED that Respondent shall pay, as
a part of the division of the estate of the parties, the following and shall indemnify and hold
Petitioner and Petitioner's property harmless from any failure to so discharge these items:
1. One-half of the balance due and owing on the _____________ card in both parties'
names.
2. One-half of the balance due and owing on the _____________ card in both parties'
names.
3. One-half of the balance due and owing on the _____________ Card in both parties'
names.
4. All encumbrances, ad valorem taxes, liens, assessments, or other charges due or to
become due on the real and personal property awarded to Respondent in this Decree
unless express provision is made herein to the contrary.
E. Notice - IT IS ORDERED AND DECREED that each party shall send to the other party,
within three (3) days of its receipt, a copy of any correspondence from a creditor or taxing authority
concerning any potential liability of the other party.
F. Federal Income Tax Liability for Prior years - IT IS ORDERED AND DECREED that
_____________ and _____________ shall be jointly responsible for all federal income tax
liabilities of the parties from the date of marriage through _____________ ___ , ______ .
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G. Method of Preparation and Filing of Tax Return for ______ - IT IS FURTHER
ORDERED AND DECREED that, for the calendar year ______ , each party shall file an individual
income tax return in accordance with the Internal Revenue Code and report as the party's income
one-half of all community income or loss attributable to the parties, or either of them, before the
date of divorce, all income attributable to the reporting party after that date, and all the reporting
party's separate income during any part of the year. Each party shall take credit on the party's return
for 50% of all prior year overpayments, estimated tax payments, and withholdings occurring before
the date of divorce and for 100% of the reporting party's estimated tax payments and withholdings
occurring after the date of divorce.
H. Allocation of Tax Liabilities for ______ - IT IS FURTHER ORDERED AND
DECREED that, for the calendar year ______ , _____________ shall timely pay and hold
_____________ and his property harmless from any federal income tax liability attributable to the
personal earnings of _____________ from _____________ ___ , ______ through the date of
divorce. IT IS FURTHER ORDERED AND DECREED that _____________ shall be entitled to
use as a credit against her tax liability all prepayments and withholdings made by _____________
before the date of divorce and all deductions, exemptions, and adjustments attributable to the
personal earnings of _____________ before the date of divorce. IT IS FURTHER ORDERED
AND DECREED that _____________ shall pay and hold _____________ and her property
harmless from any tax liability attributable to _____________ ' income from the date of divorce
until _____________ ___ , ______ . IT IS FURTHER ORDERED AND DECREED that, for the
calendar year ______ , _____________ shall timely pay and hold _____________ and her property
harmless from any federal income tax liability attributable to the personal earnings of
_____________ from _____________ ___ , ______ through the date of divorce. IT IS FURTHER
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ORDERED AND DECREED that _____________ shall be entitled to use as a credit against his tax
liability all prepayments and withholdings made by _____________ before the date of divorce and
all deductions, exemptions, and adjustments attributable to the personal earnings of
_____________ before the date of divorce. IT IS FURTHER ORDERED AND DECREED that
_____________ shall pay and hold _____________ and her property harmless from any tax
liability attributable to _____________ ' income from the date of divorce until _____________ ___ ,
______ . IT IS FURTHER ORDERED AND DECREED that each party shall be solely entitled to
use as a credit against his or her own tax liability all prepayments and withholdings made by him or
her after the date of divorce and all deductions, exemptions, and adjustments attributable to his or
her income and expenses after the date of divorce.
I. Information to be Furnished - IT IS FURTHER ORDERED AND DECREED that
_____________ and _____________ shall furnish such information to the other party as is
requested to prepare federal income tax returns for each party for the year in which the divorce
decree is entered, and in no event shall such information be exchanged later than _____________
___ , ______ . Each party shall pay for the preparation of his or her own tax return for the year in
which the divorce decree is entered.
J. Tax Refund - If a refund is made for overpayment of taxes for ______ or prior years
during the parties' marriage, each party shall be entitled to one-half of the refund, and the party
receiving the refund check is designated a constructive trustee for the benefit of the other party, to
the extent of one-half of the total amount of the refund, and shall pay to the other party one-half of
the total amount of the refund check within five (5) days of receipt of the refund check.
K. Preservation of Records - IT IS ORDERED AND DECREED that each party shall keep
and preserve for a period of four (4) years from the date of divorce all financial records relating to
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the community estate, and each party is ORDERED AND DECREED to allow the other party
access to these records in the event of any tax audits.
IT IS FURTHER ORDERED AND DECREED that each party shall furnish to the other
party all financial records relating to acquisition dates, basis, and recapture information concerning
property in which the community has had an interest.
IT IS FURTHER ORDERED AND DECREED that _____________ shall have the right to
claim the child, _____________ , as a dependent for purposes of federal income taxes.
L. Transfer of Property - IT IS ORDERED AND DECREED that _____________ shall
execute and deliver to _____________ within five (5) days, the following instruments, in the form
attached to this Decree:
1. Power of Attorney to Transfer Motor Vehicle on the _____________ awarded to
Respondent.
2. Power to Attorney to Transfer Motor Vehicle on the _____________ awarded to
Respondent.
IT IS ORDERED AND DECREED that _____________ shall execute and deliver to
_____________ within five (5) days, the following instruments, in the form attached to this Decree:
1. Power of Attorney to Transfer Motor Vehicle on the _____________ awarded to
Petitioner.
IT IS ORDERED AND DECREED, as a part of the division of the estate of the parties, that
any community liability not expressly assumed by a party under this Decree is to be paid by the
party incurring the liability.
10. Court Costs
Costs of Court are to be borne by the party by whom such costs were incurred.
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11. Clarifying Orders
Without affecting the finality of this Decree of Divorce, this Court expressly reserves the
right to make orders necessary to clarify and enforce this Decree.
12. Relief Not Granted
IT IS ORDERED AND DECREED that all relief requested in this cause and not expressly
granted is denied.
IT IS ORDERED AND DECREED that all relief requested in this cause and not expressly
granted is denied.
SIGNED on _________________________ , ______
___________________________
JUDGE PRESIDING
APPROVED AND CONSENTED TO AS TO
BOTH FORM AND SUBSTANCE:
____________________ ____________________
Signature of Petitioner Signature of Respondent
____________________ ____________________
Print Name Print Name
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THE STATE OF TEXAS
COUNTY OF _____________
POWER OF ATTORNEY TO TRANSFER AUTOMOBILE
I, _____________ , for good and valuable consideration, do hereby constitute and appoint
_____________ , my agent and attorney-in-fact, in my name, place, and stead, to convey and
transfer all of my right, title, and interest in one _____________ , Vehicle Identification Number
_____________ , to whomsoever he may desire and to execute, in my name as my attorney-in-fact,
any and all instruments necessary for such conveyance and transfer.
EXECUTED this ______ day of______________________, ______
____________________
Signature
____________________
Print Name
THE STATE OF TEXAS
COUNTY OF _____________
BEFORE ME, the undersigned authority, on this day personally appeared
________________ , known to me to be the person whose name is subscribed to the foregoing
instrument, who acknowledged to me that she executed the same for the purposes And
consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this the _______ day of
________________________________
Notary Public in and for
The State of TEXAS
THE STATE OF TEXAS
COUNTY OF _____________
POWER OF ATTORNEY TO TRANSFER AUTOMOBILE
I, _____________ , for good and valuable consideration, do hereby constitute and appoint
_____________ , my agent and attorney-in-fact, in my name, place, and stead, to convey and
transfer all of my right, title, and interest in one _____________ , Vehicle Identification Number
_____________ , to whomsoever he may desire and to execute, in my name as my attorney-in-fact,
any and all instruments necessary for such conveyance and transfer.
EXECUTED this ______ day of______________________, ______
____________________
Signature
____________________
Print Name
THE STATE OF TEXAS
COUNTY OF _____________
BEFORE ME, the undersigned authority, on this day personally appeared
________________ , known to me to be the person whose name is subscribed to the foregoing
instrument, who acknowledged to me that she executed the same for the purposes And
consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this the _______ day of
________________________________
Notary Public in and for
The State of TEXAS
THE STATE OF TEXAS
COUNTY OF _____________
POWER OF ATTORNEY TO TRANSFER AUTOMOBILE
I, _____________ , for good and valuable consideration, do hereby constitute and appoint
_____________ , my agent and attorney-in-fact, in my name, place, and stead, to convey and
transfer all of my right, title, and interest in one _____________ , Vehicle Identification Number
_____________ , to whomsoever he may desire and to execute, in my name as my attorney-in-fact,
any and all instruments necessary for such conveyance and transfer.
EXECUTED this ______ day of______________________, ______
____________________
Signature
____________________
Print Name
THE STATE OF TEXAS
COUNTY OF _____________
BEFORE ME, the undersigned authority, on this day personally appeared
________________ , known to me to be the person whose name is subscribed to the foregoing
instrument, who acknowledged to me that she executed the same for the purposes And
consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this the _______ day of
________________________________
Notary Public in and for
The State of TEXAS
