Free State of Minnesota - Minnesota

State of Minnesota
County of
Judicial District: Court File Number: Assigned Judge: Case Type:

District Court

Dissolution without Children

In Re the Marriage of:

Name of Petitioner (first, middle, last)

Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree

and Name of Respondent (first, middle, last) ------------------------------------------------------------------------------------------------------------------------------A. This proceeding for dissolution of marriage came before the undersigned judge of district court on _____________________________(date) at _____________________________(location) State of Minnesota. Petitioner did did not appear. Respondent did in the did not

appear. _______________________________ appeared as attorney for _____________________. B. Petitioner Petitioner C. Respondent Respondent D. is NOT represented by an attorney OR is represented by the following attorney: _________________________________ . is NOT represented by an attorney OR is represented by the following attorney: _______________________________ .

Service of the Summons and Petition for Dissolution of Marriage: Respondent was personally served on _________________________________, ___________, OR

Respondent signed an Admission of Service on ___________________________, ___________, OR Respondent was served by alternate means as ordered by the court as follows: By mailing the Summons and Petition to Respondent at the address(es) stated in the Order for Service by Alternate Means on this date:___________________________________________ By publication of the Summons in _______________________________________ newspaper for 3 consecutive weeks, once each week, on the following 3 dates: ____________________ , ______________________________________________, and ________________________ . E. Petitioner was served with an Answer and Counter-Petition: YES NO
Month Day Year

If YES, Petitioner was served with the Answer and Counter-Petition on ________________, ______.

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F.

Respondent did not respond, so Petitioner proceeded by default. (Note: If the parties reached an agreement, use the Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree.)

Findings of Fact
1. Information about Petitioner Full Name:
First Middle Last

Address where you live:
Street Address Apt. No. _______ City County State Zip Code

Mailing address:

Same as above address OR

Street Address

Apt. No. _______

City

County

State

Zip Code

Date of Birth: ________________________
Month Day Year

Petitioner is the

Husband

Wife.

List all of Petitioner's former or other names or write "None":

First

Middle

Last

First

Middle

Last

2.

Information about Respondent Full Name:
First Middle Last

Address:
Street Address Apt. No.

_______________________________________________________________________________
City County State Zip Code

Respondent's address is unknown to Petitioner.

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Respondent's Mailing address:

Same as above address OR

Street Address

Apt. No. _______

City

County

State

Zip Code

Respondent's Date of Birth: ________________________
Month Day Year

List all of Respondent's former or other names or write "None":
First Middle Last

First

Middle

Last

3.

Our Marriage Petitioner and Respondent were married on: (month, day, year) ,

in the City of _____________________, County of _______________________________, State of __________________________, Country of .

4.

180 Day Requirement Has Petitioner been living in Minnesota for the past six (6) months? Has Respondent been living in Minnesota for the past six (6) months? UNKNOWN YES
YES

NO
NO

5.

Armed Forces Is Petitioner an active duty member of the armed forces? YES NO YES NO

If YES, has Petitioner been stationed in Minnesota for the past six (6) months?

Is Respondent an active duty member of the armed forces?

YES

NO

UNKNOWN

If YES, has Respondent been stationed in Minnesota for the past (6) months?

YES

NO

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6.

Marriage Cannot be Saved There has been an irretrievable breakdown of my marriage relationship with Respondent and the marriage cannot be saved.

7.

Physical Living Situation Do Petitioner and Respondent live together at this time? If NO, the date of separation was:
Month Day Year

YES

NO .

If YES, Petitioner and Respondent are living together because:

8.

Other Proceedings Has a separate court case for marriage dissolution, legal separation, or annulment already been started by Petitioner or Respondent in Minnesota or elsewhere? type of court case is: YES NO If YES, the

, and it was started in

________________________ County in the State of ____________________ and the Court file number is Open Closed , and the status or outcome of the case is: Unknown or

9.

Protection or Harassment Order Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and Respondent? YES NO If YES: The Order protects: County in date, and the Court file number is "Minor" children are under age 18, or under age 20 but still in high school. YES NO . Petitioner Respondent

and the Order was filed in State on

10.

Children

a. Do Petitioner and Respondent have minor children together?

b. Do Petitioner and Respondent have any adult dependent children who are not able to support
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themselves because of a physical or mental condition?

YES

NO

c. Has Wife given birth, since marrying Husband, to a child who is not Husband's child? YES NO

If you answered NO to c, skip to d. If YES, continue below: i. Fill in the information for all children born to Wife since marrying Husband, who are not Husband's biological children. Full Name of Child Date of Birth Age

ii. Is there a Court Order naming someone other than the Husband as the father of the child(ren) listed at i? YES NO If YES, fill in: Date of Court Order County/State of Order Court Case No.

Full Name of Child

iii. Have the Wife and biological Father signed a Minnesota Recognition of Parentage (ROP) for any of the children listed in (i) above? If YES, state the full name of the child: YES NO ______________________and

attach a certified copy of the Recognition of Parentage, if not submitted with the Petition. Has the Husband signed the "Husband's Non-Paternity Statement" for any of the children listed at (i) above? YES NO

If YES, state the name of the child: and attach a certified copy of the "Husband's Non-Paternity Statement," if not submitted with the Petition. (For each minor child listed at c.(i.) there should be a paternity court order OR the Recognition of Parentage and Non-Paternity Statement to use this Dissolution Without Children form.)

d. The Wife in this marriage

is

is not now pregnant. (If the Wife is pregnant use Marriage

Dissolution With Children form.)
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11.

Public Assistance/Medical Assistance
Note: If either party is receiving public assistance from the State of Minnesota or applies for it after this proceeding is started, the Petitioner should give notice of this marriage dissolution action to the Support and Collections office for the county paying the assistance.

a. Petitioner receives public assistance from the State of Minnesota:

YES

NO

If YES, the assistance is from _______________________County. (Check all that apply): MFIP Tribal TANF General Assistance Child Care Assistance

Minnesota Care

Medical Assistance

b. Respondent receives public assistance from the State of Minnesota: YES NO
UNKNOWN

If YES, the assistance is from _______________________County. (Check all that apply): MFIP Tribal TANF General Assistance Child Care Assistance

Minnesota Care

Medical Assistance

12.

Supplemental Security Income (SSI)
Supplemental Security Income (SSI) is a Federal income supplement program. It is available to low-income people if they are over age 65, or blind, or disabled. a. Petitioner receives Supplemental Security Income:

NO

YES in the amount of

$____________ per month.

b. Respondent receives Supplemental Security Income: $____________ per month, or
UNKNOWN

NO

YES in the amount of

13.

Petitioner's Employment a. Is Petitioner employed? YES NO Is Petitioner Self-Employed? YES NO

b. Name and address of Petitioner's employer. (If Petitioner has more than one job, list the Name and Address of each employer.) ____________________________________________________________________________
Name of Petitioner's Employer (If Self-Employed, list name and business address)

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____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

Name of Petitioner's Employer (If Self-Employed, list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

14.

Petitioner's Gross Income
The Income questions ask for monthly income. If you are paid weekly, multiply your weekly income by 4.33 to get monthly income. If you are paid every two weeks, multiply by 2.17 to get monthly income. If you are paid twice a month, multiply by 2.

Source of Income Self Employment Income

Amount per month (or zero) before taxes and deductions $________________per month

Calculate net monthly self employment revenues as follows: (Annual gross revenues minus annual ordinary and necessary business expenses) divided by 12=Net Monthly Revenue. Income from all jobs Commissions from all jobs Unemployment benefits Social Security Retirement, Survivors or Disability Income Investments or Rental Income Annuity payments Pension or Disability from work or military Worker's Compensation Court-ordered spousal maintenance you receive Other ____________________
Identify Source

$________________ per month $________________ per month $________________ per month

$________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month

Total gross income

$ _______________ per month

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Does Petitioner receive child support payments?

YES

NO

If YES, Petitioner receives

child support payments from ____________________________(name(s) of payor(s)) in the total amount of $_________________per month. 15. Respondent's Employment Is Respondent employed? YES NO YES
UNKNOWN

Is Respondent Self-Employed?

NO

UNKNOWN

Name and address of Respondent's employer. (If Respondent has more than one job, list the Name and Address of each employer.) ____________________________________________________________________________
Name of Respondent's Employer (If Self-Employed list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

___________________________________________________________________________
Name of Respondent's Employer (If Self-Employed list name and business address)

____________________________________________________________________________
Employer's Street Address

City

State

Zip Code

16.

Respondent's Gross Income Petitioner has no information about Respondent's income. OR Petitioner does not have detailed information about Respondent's income, but has good reason to believe that Respondent's pay is $____________per This is Respondent's week month year,

with bonuses, overtime or commissions in the additional amount of $__________________per week deductions) or month year. Net Income (after taxes and

Gross Income (before taxes and deductions.) OR

Petitioner has detailed information about Respondent's income. (If this is true, fill out the income information below.)

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The Income questions ask for monthly income. If Respondent is paid weekly, multiply weekly income by 4.33 to get monthly income. If Respondent is paid every two weeks, multiply by 2.17 to get monthly income. If paid twice a month, multiply by 2.

Source of Income Self Employment Income

Amount per month (or zero) before taxes and deductions $________________per month

Calculate net monthly self employment revenues as follows: (Annual gross revenues minus annual ordinary and necessary business expenses) divided by 12=Net Monthly Revenue.

Income from all jobs Commissions from all jobs Unemployment benefits Social Security (SSDI or RSDI) Investments or Rental Income Annuity payments Pension or Disability from work or military Worker's Compensation Court-ordered spousal maintenance you receive Other ____________________
Identify Source

$________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month $________________ per month

Total gross income Does Respondent receive child support payments?

$ _______________ per month YES NO If YES, Respondent

receives child support payments from ____________________________(name(s) of payor(s)) in the total amount of $_________________per month.

17.

Medical / Dental Insurance a. Does Petitioner have insurance coverage through his/her employment? Medical: YES NO Dental: YES Petitioner NO Respondent and this dental insurance

If YES, this medical insurance covers: covers: Petitioner Respondent

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b.

Does Respondent have insurance coverage through his/her employment? YES YES NO NO UNKNOWN UNKNOWN Petitioner Respondent

Medical: Dental:

If YES, this medical insurance covers: and this dental insurance covers: c.

Petitioner

Respondent

Does Petitioner receive Medical Assistance or Minnesota Care through the State of YES NO

Minnesota? d.

Does Respondent receive Medical Assistance or Minnesota Care through the State of YES NO UNKNOWN

Minnesota?

18.

Spousal Maintenance
Spousal Maintenance is money paid by one spouse to the other for living expenses.

Check only one box: Petitioner and Respondent can each pay their own living expenses and do not need spousal maintenance at this time, or in the future.

Petitioner or Respondent may need spousal maintenance in the future. The court should reserve maintenance to allow either party to ask for spousal maintenance in the future because: (explain why you want to do this)

Petitioner needs spousal maintenance from Respondent now. Petitioner is __________years of age, Petitioner and Respondent have been married for _________years. Petitioner has the following education: _____________________________________________. Petitioner's gross monthly income totals $__________________. Petitioner's monthly expenses total $______________ and Petitioner is not able to maintain the standard of living established during the marriage because: . Respondent has the ability to pay Petitioner $_____________per month for spousal maintenance.
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Respondent needs spousal maintenance from Petitioner now. Respondent is __________years of age, Petitioner and Respondent have been married for _________years. Respondent has the following education:_____________________________________________. Respondent's gross monthly income totals $______________. Respondent's monthly expenses total $________________, and Respondent is not able to maintain the standard of living established during the marriage because: _______________________________________ .

Petitioner has the ability to pay Respondent $_____________per month for spousal maintenance.

19.

Vehicles
Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles etc. owned by husband or wife together or separately, including vehicles purchased after separation:

Does Petitioner own a vehicle? Does Respondent own a vehicle?

YES YES

NO NO UNKNOWN

List all vehicles owned by husband or wife together or separately: Type of Vehicle (car, boat, truck etc.) Year/Make/ Model Name(s) on Title $ $ $ $ $ $ $ $ $ $ $ $ Value Balance Owed Monthly Payment

20.

Marital Property Marital property means almost anything that you or your spouse now own that was received or bought during the marriage, even during the times you were separated. Marital Property includes household goods, furniture, jewelry, boats, real estate and other things. Marital property does not include a gift or inheritance received by one spouse alone.

Has the marital property been divided between Petitioner and Respondent already, to Petitioner's satisfaction? YES NO

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If NO, Petitioner requests the following marital property:

21.

Non-Marital Property Non-marital property means: (1) anything that you or your spouse owned before the marriage; (2) anything that you or your spouse received as a gift, bequest, devise, or inheritance, to you or your spouse alone; (3) anything that you or your spouse got in trade or in exchange for your nonmarital property; (4) anything that is an increase in the value of non-marital property; (5) anything you or your spouse received after the valuation date set by the court; or (6) anything defined as non-marital property by a valid antenuptial contract. a. Does Petitioner have non-marital property? If YES, list Petitioner's non-marital property: YES NO

. b. Does Respondent have non-marital property? If YES, list Respondent's non-marital property: YES NO UNKNOWN

___________________________________________________________________________. Cash & Accounts ­ Not including Pension and Employer-Funded Retirement Accounts Does Petitioner have money in banks, savings, cash or investments? YES NO
YES NO

22.

Does Respondent have money in banks, savings, cash or investments?
UNKNOWN

If YES, a. List all accounts owned by you alone, your spouse alone, or owned by both of you jointly including those opened after separation. "Type of account" means checking, savings, money market accounts, certificates of deposit, stocks, bonds, stock options, mutual funds, savings bonds, and Treasury Bills, etc. Do not include Pension or Employer-Funded Retirement Accounts, which are listed at #26.
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Financial Institution

Type of Account

Account #
Last 4 digits only

Amount

Belongs to:
(name on account)

XX XX XX XX XX XX

$ $ $ $ $ $

b. List cash not listed at a.: Petitioner has cash in the amount of $ Respondent has cash in the amount of $ . OR UNKNOWN

23.

Business Interest Does Petitioner have an interest in a business? Does Respondent have an interest in a business? YES YES NO NO UNKNOWN

If YES, the name of the business is ____________________________, the address is _______________________________________________________________________________ and the value is $________________. How did you arrive at this value?

24.

Manufactured Home Does Petitioner own a manufactured home? Does Respondent own a manufactured home? YES YES NO NO UNKNOWN

If either Petitioner or Respondent own a manufactured home, together or separately, complete the following information: a. Address of the manufactured home: in the city of
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b. What type of home is it? (single, double-wide etc.) c. Whose name(s) is on the title? d. When was the home purchased? e. f. What was the purchase price? $

What is the current values of the home? $

g. How did you arrive at that amount as the current value?

h. How much money is still owed on the home? $ i. If money is owed on the home, who is the money owed to? j. Do you own the land the home sits on, or do you rent a lot? Note: If you own the lot, you must list the land at Paragraph 25. Rent Own

25.

Real Property - Land, Buildings, Contracts for Deed
All real property now owned by Petitioner or Respondent together or separately must be listed. Include real property acquired before the marriage, during the marriage, and after separation.

a. Do Petitioner and Respondent jointly own real property?

YES

NO

b. Does Petitioner own real property solely in his/her own name or with someone other than Respondent? YES NO

Does Respondent own real property solely in his/her own name or with someone other than Petitioner? YES NO UNKNOWN None One Two Three

How many properties are owned by you and your spouse in total? _______

If you or your spouse own real property, separately or together, complete the following information about the property. If there is more than one piece of real property, photocopy and complete a Real Property Information page for each piece of property. Staple the additional sheets to the Stipulated

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Findings of Fact and label each sheet "Attachment to Stipulated Findings of Fact of ____________________(your names)"

Real Property Information 1. Real Estate belongs to: (List full names of all owners)_____________________________________ ________________________________________________________________________________ 2. Legal Description is: (The full legal description must be included. Copy the legal description from the deed. Do not use the property tax statement legal description. If the legal description is long, you may use an attachment. Type or print neatly.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Street Address of the real property is: ___________________________________________________________________________ City______________________________________State______________Zip Code______________ The property is in_____________________________________County. 4. Purchase date_________________(month , day, year) and purchase price:$ 5. Mortgages or loans: (List all mortgages and loans on the property) There are no mortgages or loans on this property. 1st Mortgage: Amount currently owed $ 2nd Mortgage: Amount currently owed $ and name of lender

and name of lender

Other mortgages or loans:

6. Current Market Value of this property: How did you arrive at this value?

$___________________________________

7. This property is the homestead: _______Yes
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26.

Retirement Plans Does Petitioner have a retirement account? (IRA, 401(k), 403(b) or other) YES NO If YES:

a) The account number is: (last 4 digits only) b) The name of the bank that has the account is: c) The current account balance is: Has Petitioner, or Petitioner's past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Petitioner? YES NO If YES:

a) The name of the plan is:____________________________________________________ b) The employer, union or group providing the plan is: c) The date Petitioner began working at the job or joined the union or group plan is:

d) The type of plan is: (e.g. defined benefit, defined contribution)

e) The present value of the pension or plan is: Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other) YES NO UNKNOWN If YES:

a) The account number is: (last 4 digits only) b) The name of the bank that has the account is: c) The current account balance is: Has Respondent, or Respondent's past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Respondent? YES NO UNKNOWN

If YES, and it is a Pension, Profit-Sharing, or other Retirement Plan: a) The name of the plan is:
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b) The employer, union or group providing the plan is: c) The date Respondent began working at the job or joined the union or group plan is:

d) The type of plan is: (e.g. defined benefit, defined contribution)

e) The present value of the pension or plan is: ___________________________________

27.

Debts Does Petitioner have debt? Does Respondent have debt? YES YES NO NO UNKNOWN

If YES, list debts in your name, your spouse's name and in both names jointly. Include unpaid debts from before the marriage date, during the marriage, and after separation. Fill in all information completely and attach another sheet of paper if necessary. Money is owed to: Money was used Whose Name is on the Account for: and When was the Debt Incurred? Name Date $ $ $ $ $ $ $ $ $ $ $ Total Debt $ Balance Owed Monthly Payment

$ $ $ $ $ $ $ $ $ $ $ $

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28.

Name Change Does Petitioner want to change his/her name? a. Petitioner's name should be changed to: YES NO If YES, answer (a) through (c):

first

middle YES

last NO If NO, the reason Petitioner

Is this a former legal name or maiden name? wants to change to this name is:

b. Petitioner has no intent to defraud or mislead anyone by changing his/her name: True False.

c. Has Petitioner been convicted of a felony?

YES

NO

If YES:

i. Notice of this request for name change has been given to the proper authority as required by Minn.Stat.§259.13. (IMPORTANT NOTICE: If you are a convicted felon and you request a name change without following the requirements of Minn. Stat § 259.13, using the new last name after your divorce is a gross misdemeanor.) ii. An Affidavit of Service of the Notice marked Exhibit "A" has been submitted along with this Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree.

29.

Other Findings ___________________________________________________________________________

BASED UPON THE ABOVE INFORMATION, the Court makes the following: CONCLUSIONS OF LAW 1. The bonds of matrimony between Petitioner and Respondent are dissolved, so they are single and not married.
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2.

Medical and Dental Insurance for the Parties a. Each party to provide for his or her own b. medical dental insurance. medical dental

____________________________(full name) shall provide

insurance for ______________________________________________ (full name). c. Allowing____________________________(full name), at his/her own expense, to continue the dependent coverage available under the other party's insurance plan, pursuant to federal and state statutes. d. Reserving the issue of medical and dental insurance for the parties. 3. Spousal Maintenance a. Neither party is awarded spousal maintenance. b. Maintenance is reserved because: . Either party can ask the court to order the payment of spousal maintenance in the future by filing a Motion stating a change in circumstances. c. Petitioner Respondent shall pay permanent spousal maintenance to the other

party in the amount of $ _________ per month starting on (date):________________________. Any past due amounts are still owed. d. Petitioner Respondent shall pay temporary spousal maintenance to the other party in

the amount of $ _________ per month starting on (date): ______________________________ and ending:_____________________________________. Any past due amounts are still owed.

The monthly amount of permanent or temporary spousal maintenance shall be: subject to income withholding from the payor's income, regardless of source, by his or her employer, trustee, or other payor of funds and mailed to: Minnesota Child Support Payment Center, P.O. Box 64326, St. Paul, MN 55164-0326. If the person paying spousal support is selfemployed, send payments to Minnesota Child Support Payment Center, P.O.Box 64306, St. Paul, MN 55164-0306. To start income withholding, Petitioner or Respondent must apply for income withholding at the Child Support Office in their county. Until income withholding starts, the person owing maintenance shall pay the amount directly to the spouse receiving it.
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OR Maintenance shall be paid directly by the spouse owing the maintenance to the spouse receiving it, payable on the ____________________day of each month. 4. Vehicles Awarding the vehicles as follows and ordering the party receiving the vehicles to pay for any loans or insurance for such vehicle: Year / Make / Model Awarded to:

5.

Marital Property The parties' marital property, household goods, furniture and furnishings are awarded: a. As currently divided OR b. As follows (add pages if necessary): To Petitioner:

To Respondent:

6.

Non-Marital Property The parties' non-marital property is awarded: a. As currently divided OR b. As follows (add pages if necessary):

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To Petitioner:

To Respondent:

7.

Cash and Accounts a. Awarding the savings and investments as follows: Institution Type of Account Account #
(Last 4 digits only)

Amount $ $ $ $ $ $

Awarded to

XX XX XX XX XX XX

b.

Awarding any cash not included in a. above to the party who currently has the cash OR Awarding the cash as follows:

8.

Business None OR Awarding the parties' business as follows: _________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

9.

Manufactured Home None OR Awarding the manufactured home located at :
street address city state

to

Petitioner

Respondent. The debt on the manufactured home owed to: shall be paid by Petitioner Respondent.
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10.

Real Property None OR Awarding solely to Petitioner Respondent all right, title, and interest of husband

and wife in the real property located at: Street address___________________________________________________________________ in the City of State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Respondent: 1st Mortgage: Amount currently owed: $ 2nd Mortgage: Amount currently owed: $ and name of lender: Petitioner

and name of lender:

and subject to the following liens or other agreements: A lien in favor of Petitioner Respondent in the amount of $ .

Other request regarding the property: (describe the request fully)

11.

Additional Real Property None OR Awarding solely to Petitioner Respondent all right, title, and interest of husband and

wife in the real property located at:
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Street address___________________________________________________________________ in the City of State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Respondent: 1st Mortgage: Amount currently owed: $ and name of lender: Petitioner

2nd Mortgage: Amount currently owed: $

and name of lender:

and subject to the following liens or other agreements: A lien in favor of Petitioner Respondent in the amount of $ .

Other request regarding the property: (describe the request fully)

12.

Retirement Funds a. Awarding Petitioner's pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: Petitioner has no retirement funds OR 100% to Petitioner OR

Dividing Petitioner's retirement benefits fairly and equitably between the parties as follows:

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b. Awarding Respondent's pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: Respondent has no retirement funds OR 100% to Respondent OR Dividing Respondent's retirement benefits fairly and equitably between the parties as follows:

13.

Debts a. Dividing the debts as follows and ordering each party to hold the other harmless from any responsibility for the debts so divided. Include all debts listed at #27 above. Debt Owed To: To Be Paid By:

b. Ordering that each party is solely responsible for paying any other debts incurred solely by him or her and ordering each party to hold the other harmless from any responsibility for such separately incurred debts.

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14.

Name Change Petitioner is not requesting a name change. Changing Petitioner's name to:

First

Middle

Last

15.

Other:

16.

Other:

17.

Each party shall execute any and all documents necessary to transfer real and personal property as awarded herein without further order of the Court. Should either party fail to execute the

necessary documents, a certified copy of the Judgment and Decree shall operate to transfer title as awarded.

18.

Petitioner shall personally serve Respondent with a copy of the Judgment and Decree by having a third party (the server), age 18 or older, hand a copy of the Judgment and Decree to Respondent. The server's Affidavit of Service, filed with the Court by Petitioner, will be proof of service.

NOTICE: APPENDIX A SHALL BE INCORPORATED AND MADE A PART OF THE JUDGMENT AND DECREE. Appendix A contains provisions regarding Payments to Public Agency, Minnesota Statutes § 518A.50; Depriving Another of Custodial or Parental Rights--A Felony, Minnesota Statutes § 609.26; Rules of Support, Maintenance, Parenting Time; Parental Rights from Minnesota Statutes § 518.17, subdivision 3; Wage and Income Deduction of Support and Maintenance, Minnesota Statutes § 518A.53; Change of Address or Residence; Cost of Living Increase of Support and Maintenance pursuant to Minnesota Statutes § 518A.75; Judgments for Unpaid Support pursuant to Minnesota Statutes § 548.091; Judgments for Unpaid Maintenance pursuant to Minnesota Statutes
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§548.091; Medical Insurance and Expenses pursuant to Minnesota Statutes § 518A.41; and Minnesota Statutes § 259.115 regarding criminal penalties for failure to comply with felon name change law.

ORDER FOR JUDGMENT LET JUDGMENT BE ENTERED IMMEDIATELY. The foregoing facts were found by me after due hearing and the Order thereon is recommended. BY THE COURT

District Court Referee Dated:_____________________

Judge of District Court Dated:_______________________________

JUDGMENT I certify the above Conclusions of Law are the Judgment of the Court. ___________________________________________
Court Administrator

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