Free State of Minnesota - Minnesota

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

District Court

Dissolution with Children

In Re the Marriage of:
Name of Petitioner (first, middle, last)

and Name of Respondent (first, middle, last)

Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree (Gen. R. Prac. Rule 308.04)

------------------------------------------------------------------------------------------------------------------------------A. This proceeding for dissolution of marriage came before the undersigned judge of district court on _____________________________(date) at _____________________________(location) State of Minnesota. appear. ______________________________________ appeared as attorney for _____________________. Petitioner did did not appear. Respondent did in the did not

B.

Petitioner Petitioner

is NOT represented by an attorney OR is represented by the following attorney: _________________________________ .

C.

Respondent Respondent

is NOT represented by an attorney OR is represented by the following attorney: _______________________________ .

D.

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

Respondent signed an Admission of Service on ___________________________, ___________, OR 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 ________________________ .
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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 ________________, ______.

F. Petitioner and Respondent have reached an agreement for marital termination resolving all issues in this case. Petitioner prepared the Findings of Fact, Conclusions of Law, Order for Judgment and Judgment and Decree and incorporated the stipulated facts and terms of the parties' agreement. A signed Acknowledgement regarding this agreement is also included in this document.

FINDINGS OF FACT 1. Information about Petitioner Full Name: _______________________________________________________________________
First Middle Street Address Last Apt. No. _______ City County State Zip Code

Address:

Mailing address where Petitioner agrees to receive papers for this case: OR

Same as above address

________________________________________________________________________

Street Address City County State

Apt. No. _______ 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 First

Middle Middle

Last Last

2. Information about Respondent Full Name:
First Middle Last

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Address:
Street Address Apt. No.

City

County

State

Zip Code

Date of Birth: ________________________
Month Day Year

List all of Respondent's former or other names or write "None":
First First Middle Middle Last 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? 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 YES NO

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

6.

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

7.

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

NO .

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If YES, Petitioner and Respondent are living together at this time because:

8.

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

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

b. Has a County started a Support case involving the Petitioner and the Respondent or their children? YES NO If YES, the case was started in ________________________ .

County in the State of ____________________ and the Court file number is The case is Dismissed or Pending or an Order for Support was issued.

9.

Protection or Harassment Order Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and Respondent? If YES: a. The Order protects: in Petitioner Respondent the child(ren) and the Order was filed State on . YES NO YES NO

County in date, and the Court file number is

b. Does the Order for Protection include an order to pay child support?

10.

Juvenile Court Case Is a Juvenile Court case (child protection, delinquency or foster care) involving the joint child(ren) of Petitioner and Respondent taking place in Minnesota or another state? If YES, the case is in Court file number is in the Juvenile Court case is: . YES NO

County in the State of __________________ and the . The name of the child or children involved

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11.

Children Petitioner and Respondent have Together (Joint Children)
"Child" means a living person under age 18, or under age 20 and still in high school.

a. Are there any children born to or adopted by husband and wife together, either before or during the marriage? YES NO If YES, Child Currently Lives With Petitioner Respondent Both parents OR _______________________(write in name) Respondent Both parents

Full Name of Child Date of Birth Age

Petitioner OR

________________________(write in name) Respondent Both parents

Petitioner OR

________________________(write in name) Respondent Both parents

Petitioner OR

________________________(write in name) Respondent Both parents

Petitioner OR

________________________(write in name)

If a child is living with someone other than a parent, write the child's address below: Address: ______________________________________________________________________
Street Address City County State Apt. No. Zip Code

b. Has each child born to or adopted by Petitioner and Respondent together lived in Minnesota for the past six (6) months? YES NO

If NO, name the child or children, name the State(s) the child has lived in during the past 6 months, and the dates the child lived in each state:

12.

Adult Dependent Children
Support can be ordered for a joint child over age 18 who cannot support him/herself because of a physical or mental condition.

Is there an adult joint child born to or adopted by Petitioner and Respondent who is not able to support himself or herself because of a physical or mental condition? If YES, the full name, date of birth and age of each adult dependent is: YES NO

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Full Name of Dependent

Date of Birth

Age

13.

Pregnancy a. b. Petitioner Is wife pregnant? Respondent is the wife in this marriage. YES NO

If wife is pregnant answer (i) and (ii): (i) The date the baby is due is
Month Day Year

(ii) Do Wife and Husband agree that husband is the biological father of the unborn child? YES If NO, 14. NO Wife Husband claims husband is not the biological father of the child.

Husband's Children from Other Relationship (Nonjoint Children) Does Husband have minor child(ren) from another marriage or relationship? YES NO

If YES, the full name, date of birth and age of each child is: Full Name of Child and Age Date of Birth Does Child Live with Husband? YES NO YES YES YES YES NO NO NO NO Is Husband Court-Ordered to pay Child Support for this Child? YES NO YES YES YES YES NO NO NO NO

15.

Wife's Children from Other Relationship (Nonjoint Children) a. Does Wife have minor child(ren) born prior to the marriage from another marriage or relationship? YES NO

If YES, the full name, date of birth and age of each child born prior to the marriage is: Full Name of Child and Age Date of Birth Does Child Live with Wife? YES NO
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Is Wife Court-Ordered to pay Child Support for this Child? YES NO
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YES YES YES

NO NO NO

YES YES YES

NO NO NO

b. Has Wife given birth, since marrying Husband, to a minor child who is not a child of the Husband? YES NO

If YES, answer (i) , (ii), (iii) and ( iv): (i) List the full name, date of birth and age of each child born to Wife since marrying Husband, who is not a child of the Husband: Full Name of Child and Age Date of Birth Does Child Live with Wife? YES NO YES NO Is Wife Court-Ordered to pay Child Support for this Child? YES NO YES NO

(ii)

Is there a Court Order naming someone other than the Husband as the father of the child(ren) listed in (i) above? YES NO

(iii)

Have the Wife and biological Father signed a Minnesota Recognition of Parentage for any of the children listed in (i) above? If YES, state the full name of the child: submit a copy of the Recognition of Parentage. If NO, why not? YES NO and

(iv)

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 submit a copy of the "Husband's Non-Paternity Statement." If NO, why not?

16.

Custody It is in the child's best interests and we agree that legal custody be granted as follows: one) (check

Joint legal custody to both parents
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Sole legal custody to Husband Wife
It is in the child's best interests and we agree that physical custody be granted as follows: (check one)

Joint physical custody to both parents Sole physical custody to Husband Wife
17. Parenting Time a. It is in the best interests of the children that: Petitioner's parenting time with the joint children be: (check one) unsupervised supervised reserved

Respondent's parenting time with the joint children be: (check one) unsupervised supervised reserved

If parenting time is unsupervised for both parents, skip to Question 18.

b. supervised parenting time (Option 1) Supervision is necessary because unsupervised parenting time is likely to endanger the child's physical or emotional health or impair the child's emotional development. The circumstances supporting this finding are:

(Option 2) We agree that supervised parenting time is necessary because

It is in the best interests of the child(ren) that supervision of parenting time be arranged as follows: (State who should supervise parenting time, and if there is a cost involved, who should pay the cost, and any other important details)

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c. Reserved Parenting time We agree that parenting time should be reserved because:

18.

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

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

YES

NO

If YES, the assistance is from __________________ County. (Check all that apply): MFIP in the amount of $___________per month Tribal TANF in the amount of $__________per month General Assistance in the amount of $___________per month Child Care Assistance MinnesotaCare Medical Assistance

b. Respondent receives public assistance from the State of Minnesota:

YES

NO

If YES, the assistance is from __________________ County. (Check all that apply): MFIP in the amount of $___________per month Tribal TANF in the amount of $__________per month General Assistance in the amount of $___________per month Child Care Assistance c. MinnesotaCare Medical Assistance

The joint children of the parties receive public assistance from the State of Minnesota: YES NO

If YES, the assistance is from __________________ County. (Check all that apply): MFIP Medical Assistance Tribal TANF MinnesotaCare

IV-E Foster Care

19.

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

a.

Petitioner receives Supplemental Security Income (SSI): $___________per month.

NO

YES in the amount of

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b.

Respondent receives Supplemental Security Income (SSI): $___________per month.

NO

YES in the amount of

c.

The joint children of the parties receive Supplemental Security Income (SSI): NO YES in the amount of $___________per month. What is the name of the child

Receiving SSI?____________________________________________________________ Petitioner's Employment a. Petitioner is employed: YES NO Petitioner is Self-Employed: YES NO YES NO

20.

b. Petitioner is working at least 40 hours per week:

If Petitioner is unemployed or working less than 40 hours/week, answer these questions: i. Why is Petitioner unemployed or working less than 40 hours/week.

ii. What is Petitioner's past work experience (type of jobs, hours, pay, length of time at the job) and what are Petitioner's professional qualifications or licenses?

c. Current Employment: (If Petitioner currently has more than two jobs, use an attachment for the additional jobs.) ____________________________________________________________________________
Name of Petitioner's Employer (If Self-Employed, list name and business address)

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

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

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

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Questions about Current Jobs Is Petitioner paid by the hour or salaried? What is the average number of hours Petitioner works per week?

1st Job hourly salary

2nd Job hourly salary

________________hours

________________hours

How much overtime pay does Petitioner receive per week on $_____________________ $____________________ average? Does Petitioner receive bonuses? If Yes, how much was received in If Yes, how much was received in Yes Yes No 1st Job No 2 Job
nd

bonuses last year? $_____________

bonuses last year? $_____________

How much do you expect to receive How much do you expect to receive this year? $___________ this year? $___________

21. Petitioner's Income Source of Income Self Employment Income
minus ordinary and necessary business expenses.

Amount Per Month (or zero) before deductions/taxes $________________ per month

Self Employment income means gross receipts minus costs of goods sold

Job with __________________________ Second Job with _____________________ Third Job with ______________________ Commissions from all jobs Unemployment benefits Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) Investment and Rental Income Annuity payments Pension or Disability from work or military Worker's Compensation Court-ordered spousal maintenance you receive Other income____________________________
Identify Source

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

Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Divide the total amount you expect this year by 12 to get a monthly average

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

Add all of the above.

Total monthly income

$ ________________ per month

Enter the amount of child support Petitioner is court-ordered
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to pay for any nonjoint child(ren)

$________________ per month

Enter the amount of spousal maintenance Petitioner is court-ordered to pay to a current or former spouse $________________ per month Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Petitioner's retirement, disability, or other eligibility $________________ per month Which parent receives the payment for the child? Petitioner Respondent

22.

Living Expenses for the Family a. Petitioner and Respondent and their children are still living together. Current monthly living expenses for the family total $ OR b. Petitioner and Respondent are living separately. The monthly family living expenses before separation totaled $ . At this time, Petitioner's separate monthly .

living expenses total $____________, and Respondent's monthly living expenses total $______________. Of the total current monthly living expenses for Petitioner,

$_______________ amount is for expenses just for the children that live with Petitioner. Of the total current monthly living expenses for Respondent, $___________is for expenses just for the children that live with Respondent.

23.

Expenses for Special Needs for the Children a. Is there a joint child of the parties who has special needs and extraordinary medical expenses? YES NO If Yes,

Name of child with special needs: Describe the needs:

b. Does Petitioner's monthly living expense (stated at #22) include the special needs expenses for the child? YES NO c. Does Respondent's monthly living expense (stated at #22) include the special needs expenses for the child? 24. YES NO Respondent's Employment a. Respondent is employed: YES NO Respondent is Self-Employed: YES NO
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YES

NO

b. Respondent is working at least 40 hours per week?
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If Respondent is unemployed or works less than 40 hours/week, answer these questions: i. Explain why Respondent is not working or why Respondent works less than 40 hours/week

ii. What is Respondent's past work experience (type of jobs, hours, pay, length of time at the job) and professional qualifications or licenses?

c. Current Employment: (If Respondent currently has more than two jobs, use an attachment for the additional
jobs.)

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

____________________________________________________________________________
Employer's Street Address

____________________________________________________________________________
City State Zip Code

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

____________________________________________________________________________
Employer's Street Address

City

State

Zip Code

Questions about Jobs Is Respondent paid by the hour or salaried? What is the average number of hours Respondent works per week?

1 Job hourly salary

st

2 Job hourly salary

nd

________________hours

________________hours

How much overtime pay does Respondent receive per week on $_____________________ $____________________ average? Does Respondent receive bonuses? If Yes, how much did Respondent If Yes, how much did Respondent Yes Yes No 1st Job No 2 Job
nd

receive

in

bonuses

last

year? receive

in

bonuses

last

year?

$___________

$_________

How much does Respondent expect How much does Respondent expect to receive this year? $___________ to receive this year? $___________

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25.

Respondent's Income Sources of Income Amount Per Month (or zero) before deductions/taxes

Self Employment Income

$___________________ (or zero)

Self Employment Income means gross receipts minus costs of goods sold minus ordinary and necessary business expenses.

Job with______________________________ Second job with________________________ Commissions from all jobs Unemployment benefits

$ ___________________ per month $____________________ per month $____________________ per month $____________________ per month

Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Divide the total amount expected this year by 12 to get a monthly average

Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) Investment and Rental Income Annuity payments Pension or Disability from work or military Worker's Compensation Court-ordered spousal maintenance you receive Other income____________________________
Identify Source

$____________________ per month $____________________ per month $_____________________ per month $_____________________ per month $_____________________ per month $ ____________________ per month $____________________ per month

Add all of the above.

Total monthly income

$ ____________________ per month

Enter the amount of child support Respondent is court-ordered to pay for any nonjoint child(ren) $____________________ per month Enter the amount of spousal maintenance Respondent is court-ordered to pay to a current or former spouse $____________________ per month Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Respondent's retirement, disability, or other eligibility $_____________________ per month Which parent receives the payment for the child? Petitioner Respondent

26.

Child Care Costs Are there child care costs for joint children because of work or school? YES NO
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If YES, a. How many of the joint children need child care? One Two Three ______________

b. How much does the daycare center(s) or babysitter charge per month? $ c. Does the County child support agency pay for child care through a subsidy or child care assistance? Yes, child care assistance is being received. . Husband's Wife's

co-pay for child care per month is $ No, there is no county child care assistance received. d. The parties agree that Husband should pay $ proportional share of child care costs and Wife should pay $

per

month per are

for

his

month

for her proportional share of child care costs. These amounts upon calculations using the child support guidelines worksheet.

are not based

27.

Health Care Coverage a. Who receives Minnesota Care or Medical Assistance? Petitioner Respondent Joint Children No one

b. Does Petitioner have medical insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to c.

i. Where does Petitioner get the medical insurance? through his/her employment buys private medical insurance ii. How much does the medical insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage iii. Who is currently covered by this medical insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered_____________________________________

c. Does Petitioner have dental insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to d.

i. Where does Petitioner get the dental insurance? through his/her employment buys private dental insurance ii. How much does the dental insurance cost?
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$____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage Or, Dental is included in the medical insurance costs.

iii. Who is currently covered by this dental insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered____________________________________

d. Does Respondent have medical insurance? (other than MN Care or Medical Assistance) Yes No If No, skip to e.

i. Where does Respondent get the medical insurance? through his/her employment buys private medical insurance ii. How much does the medical insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage iii. Who is currently covered by this medical insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered____________________________________

e. Does Respondent have dental insurance? (other than MN Care or Medical Assistance) Yes No If No, skip to f.

i. Where does Respondent get the dental insurance? through his/her employment buys private dental insurance ii. How much does the dental insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage Or, Dental is included in the medical insurance costs.

iii. Who is currently covered by this dental insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children

Name the joint children who are covered_____________________________________

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f. If the joint children are without health care coverage, is coverage available for purchase through Petitioner's or Respondent's employer? coverage. g. Other: YES NO The joint children currently have health

28.

Basic Support:

Basic support is for a child's housing, food, clothing, transportation,

education costs, and other expenses related to the child's care. Husband $ Wife shall pay basic support to the other party in the amount of

per month by the first day of the month, starting the first month after Payment shall be through income withholding. This

entry of the judgment for divorce.

amount is based on the calculations from the child support guidelines worksheet, which is attached and incorporated into this Marital Termination Agreement. Husband $ Wife shall pay basic support to the other party in the amount of

per month by the first day of the month, starting the first month after Payment shall be through income withholding. This

entry of the judgment for divorce.

amount is a deviation from guidelines. The parties agree that this amount adequately meets the needs of the child(ren) and is in the best interests of the child(ren).

29.

Spousal Maintenance a. Does Petitioner need spousal maintenance from Respondent? YES NO If YES,

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 $ maintenance.

per

month

for

spousal

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b. Does Respondent need spousal maintenance from Petitioner?

YES

NO

If YES,

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 $ maintenance.

per

month

for

spousal

c. Do both parties agree that neither party needs spousal maintenance?

YES

NO If YES,

both parties agree that each party is fully capable of self-support and is not dependent upon the other for additional support in the form of spousal maintenance. Each party has made a full and fair disclosure of all income and assets, and liabilities that each is responsible for, and agree that this waiver is reasonable. The waiver is fair and equitable and is supported by the above consideration and was signed by both parties after full financial disclosure to each other.

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

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

YES YES

NO NO

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

30.

Marital Property
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DIV806

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

Has the marital property been divided already in a manner satisfactory to Petitioner and Respondent? YES NO

If NO, Petitioner requests the following marital property:

________________________________________________________________________________ ________________________________________________________________________________ If NO, Respondent requests the following marital property:

________________________________________________________________________________ ________________________________________________________________________________ 31. Non-Marital Property
Non-marital property means: (1) anything that you or your spouse owned before the marriage; (2) anything that you or your spouse received as a gift, bequest, devise, or inheritance, to you or your spouse alone; (3) anything that you or your spouse got in trade or in exchange for your non-marital property; (4) anything that is an increase in the value of non-marital property; (5) anything you or your spouse received after the valuation date set by the court; or (6) anything defined as non-marital property by a valid antenuptial contract.

a.

Does Petitioner have non-marital property? If YES, list Petitioner's non-marital property:

YES

NO

b.

Does Respondent have non-marital property?

YES

NO

If YES, list Respondent's non-marital property:

___________________________________________________________________________. Cash & Accounts ­ Not including Pension and Employer-Funded Retirement Accounts Does Petitioner have money in banks, savings, cash or investments? Does Respondent have money in banks, savings, cash or investments? If YES, YES
YES

32.

NO
NO

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a.

List all accounts owned by one spouse alone or owned by both spouses jointly including those

opened after separation. "Type of account" means checking, savings, money market accounts, certificates of deposit, stocks, bonds, stock options, mutual funds, savings bonds, and Treasury Bills, etc. Do not include Pension or Employer-Funded Retirement Accounts, which are listed at #36. 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 $ . .

33.

Business Interest Does Petitioner have an interest in a business? Does Respondent have an interest in a business?

YES YES

NO NO

If YES, the name of the business is ____________________________, the address is ________________________________________________________________________________ and the value is $________________. This value is based on:

34.

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

If either Petitioner or Respondent own a manufactured home, together or separately, complete the following information: a. Address of the manufactured home:
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in the city of

, state of

b. What type of home is it? (single, double-wide etc.) c. Whose name(s) is on the title? d. When was the home purchased? e. 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? Rent Own

Note: If you own the lot, you must list the land at Paragraph 35.

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

a. b.

Do Petitioner and Respondent jointly own real property?

YES

NO

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

c.

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

d.

How many properties are owned by Petitioner and Respondent in total? None One Two Three _______

If Petitioner or Respondent own real property, separately or together, complete the following information about the property. If there is more than one piece of real property, photocopy and complete a Real Property Information page for each piece of property. Staple the additional sheets to this Decree, and label each sheet "Attachment to Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree of

(your names) Real Property Information 1. Real Estate belongs to: (List full names of all owners)_____________________________________ ________________________________________________________________________________
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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 $ and name of lender

2nd Mortgage: Amount currently owed $

and name of lender

Other mortgages or loans:

6. Current Market Value of this property: How was this value determined?

$___________________________________

7. This property is the homestead: _______Yes 36. Retirement Plans a.

_________No

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:
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c) The current account balance is: b. Has Petitioner, or Petitioner's past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Petitioner? YES 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: NO

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

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

If YES, and it is a Pension, Profit-Sharing, or other Retirement Plan: a) The name of the plan is: 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: ___________________________________

37.

Debts Does Petitioner have debt? Does Respondent have debt? YES YES NO NO
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If YES, list debts in Petitioner's name, Respondent'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 $ $ $ $ $ $ $ $ $ Balance Owed Monthly Payment

$ $ $ $ $ $ $ $ $

Total Debt 38. Name Change a. Neither person wants to change his/her name. b. first Wife

$ $

$ $

Husband wants to change his/her name to: (full name, not initials) middle last

This name change request is made with no intent to defraud or mislead anyone: True False.

The person requesting the name change has 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
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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 Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree.

39. Other Findings ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

BASED UPON THE ABOVE INFORMATION, the parties agree that the Court shall make the following: CONCLUSIONS OF LAW 1. The bonds of matrimony between Petitioner and Respondent are dissolved, so they are single and not married. 2.
Legal Custody means which parent(s) have a say in the major decisions regarding the child(ren)'s life including education, religious upbringing and medical treatment.

It is in the best interests of the child(ren) to grant legal custody of each minor joint child of the parties as follows: Name of Child Granting Legal Custody: Solely to Petitioner OR both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties.
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Solely to Respondent OR

Jointly to

Solely to Respondent OR

Jointly

Solely to Respondent OR

Jointly

Solely to Respondent OR

Jointly

Solely to Respondent OR

Jointly

3.

Physical custody identifies which parent(s) will handle the routine daily care and control of the child(ren).

It is in the best interests of the child(ren) to grant physical custody of each of the minor joint child(ren) of the parties as follows: Name of Child Granting Physical Custody: Solely to Petitioner OR both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly to

4.

Parenting Time a. Petitioner's parenting time shall be: b. Respondent's parenting time shall be: Unsupervised Unsupervised Supervised Supervised Reserved Reserved

c. Parenting Time shall be scheduled as follows: (Clearly explain the time each parent will spend with each child. Include the time (o'clock) when the child will transfer from one parent to the other. If you want the order to say who will pick up and drop off the child, include that under "Other.") Regular schedule: Monday through Friday:

Weekends:

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Summer (if you want a different schedule in summer)

Telephone contact with the child(ren):

Unlimited or

Only at certain times as follows:

(describe the days and times when the parent and child(ren) may have telephone contact)

Exceptions to the Regular Schedule: You can have a different schedule for holidays, school release days, and birthdays. If you do not want a different schedule, leave it blank. School Release days or breaks during the school year

Any school release day schedule will supercede the regular parenting schedule.

Birthdays (child's birthday, parent's birthday)

Holidays

Any holiday or birthday schedule will supercede the regular and school release parenting schedule. Other

d. Under the above Schedule: The children are with Petitioner: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time

The children are with Respondent: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time

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5.

Basic Support for the Joint Children (Fill in a. or b.) a. Petitioner Respondent shall pay to Petitioner Respondent $___________

per month starting on (date):___________________as the basic support obligation for the parties' minor child(ren). Any past due amounts of child support are still owed. This amount is a deviation from the basic support obligation under Minnesota laws. The facts supporting the deviation from the basic amount are:

The monthly amount 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 child 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

IV-D services or income withholding-only services at the Child Support office in the County where the children live. Until income withholding starts, the person owing support shall pay the other parent directly. OR The monthly amount shall be paid directly by the parent owing the child support to the parent receiving the child support, payable on the ____________________day of each month.

b. Child Support shall be reserved because:

Either party can ask the court to order the payment of child support in the future by filing a Motion stating that there is a change in circumstances.

6.

Medical and Dental Insurance for the Joint Children Ordering Medical insurance as follows: a. Petitioner Respondent shall provide medical insurance for the joint child(ren)

through his/her employer or union. The other parent must pay a pro rata share of the health
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coverage costs by paying_________________________ OR

pay nothing toward the

medical insurance costs because he/she is financially unable to contribute to the costs. OR b. Petitioner Respondent shall provide medical insurance for the joint child(ren) by

obtaining and paying for private insurance. The other parent must pay a pro rata share of the health coverage costs by paying OR pay nothing toward the

medical insurance costs because he/she is financially unable to contribute to the costs. OR c. Petitioner Respondent shall pay $ per month, per joint child, as

reimbursement for Medical Assistance or Minnesota Care, payable by income withholding through the Minnesota Child Support Payment Center, provided Medical Assistance or Minnesota Care is open for the joint child(ren). OR d. Reserving the issue of medical insurance for the joint children.

Ordering Dental Insurance as follows: a. Petitioner Respondent shall provide dental insurance for the joint child(ren)

through his/her employer or union. The other parent must pay a pro rata share of the dental coverage costs by paying OR pay nothing toward the dental insurance

costs because he/she is financially unable to contribute to the costs. OR b. Petitioner Respondent shall provide dental insurance for the joint child(ren) by

obtaining and paying for private insurance. The other parent must pay a pro rata share of the dental coverage costs by paying OR pay nothing toward the dental insurance costs

because he/she is financially unable to contribute to the costs. OR c. Reserving the issue of dental insurance. Other:______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________.

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7.

Uninsured and Unreimbursed Medical and Dental Expenses for the Joint Child(ren) a. Petitioner shall pay _________ % of the uninsured and/or unreimbursed medical and dental costs for the minor child(ren) of the parties, and Respondent shall pay __________ % based on the percentage share of combined PICS (parental income for determining child support.)

The parent who paid the bill must ask the other parent to pay his/her percentage share. To ask for payment, send to the other parent a) a copy of the bill, b) evidence that you have paid the bill, and c) a letter requesting payment to you in the amount of $_____. This request for payment should be made promptly, and no later than 3 months after the bill is paid. If a request for payment is made after 3 months, there must be exceptional circumstances to support the late request for payment.

The person receiving the request for payment shall make the payment within 30 days. If there is a good reason to question the payment, send a letter to the other parent stating what additional information is needed, or why payment is disputed. If neither payment nor a written letter disputing payment is sent within 30 days of receiving the request for payment, then the unpaid bill can be considered back due child support. OR b. Reserving the issue of uninsured and unreimbursed medical and dental costs. "Uninsured and unreimbursed medical and dental costs" are expenses not covered by insurance and not paid by medical assistance or MinnesotaCare. Examples include deductibles, co-pays, and procedures not covered by insurance or assistance. Usually the parent with physical custody of the child will receive and pay the bill for the unreimbursed costs.

8.

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

b. ____________________________(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.

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9.

Child Care Support a. Petitioner shall pay $ and Respondent shall pay $ b. Reserving the issue of child care expenses. per month for child care expenses, per month for child care expenses; OR

10.

Spousal Maintenance a. Neither party is awarded spousal maintenance. Petitioner and Respondent have waived any claims to spousal maintenance for the past, present, or future, and expressly waive all rights to modify their waivers of maintenance. This court is divested of jurisdiction to award or modify maintenance in the future pursuant to Karon v. Karon, 435 N.W. 2d 501 (Minn. 1989). Consideration for this agreement is: (check all that apply) the parties' mutual waivers of maintenance the property settlement the parties' respective incomes and ability to earn income other: The Court has reviewed this agreement and finds it to be fair and equitable under all of the circumstances, and supported by sufficient consideration including the parties' mutual waivers, incomes per year and the property division. circumstances has occurred. 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 in the amount of $ amounts are still owed. d. Petitioner in the amount of $ (date): Respondent shall pay temporary spousal maintenance to the other party per month starting on (date): and ending on Respondent shall pay permanent spousal maintenance to the other party per month starting on (date): . Any past due Full disclosure of each party's financial

. Any past due amounts are still owed.

The monthly amount of permanent or temporary spousal maintenance shall be:
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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. OR maintenance shall be paid directly by the spouse owing the maintenance to the spouse receiving it, payable on the _____________day of each month. 11. Vehicles The vehicles are awarded as follows, and the party receiving the vehicle shall pay

for any loans or insurance for such vehicle:
Year / Make / Model Awarded to:

12.

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:

13.

Non-Marital Property The parties' non-marital property is awarded: a. As currently divided OR

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b. As follows (add pages if necessary): To Petitioner:

To Respondent:

14.

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:

15.

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

16.

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

city

state

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to

Petitioner

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

17.

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 conditions or agreements: A lien in favor of Petitioner Respondent in the amount of $ .

Other conditions or agreements about the property:

18.

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: Street address___________________________________________________________________ in the City of State of , County of ___________________________, , which has the following legal description: ______________

_______________________________________________________________________________
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_______________________________________________________________________________ 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 conditions or agreements: A lien in favor of Petitioner Respondent in the amount of $ .

Other conditions or agreements about the property:

19.

Retirement Funds a. Awarding Petitioner's pension, profit sharing, retirement plan, I.R.A., 401(k) or other retirement fund as follows: 100% to Petitioner OR

Other (describe fully):

b. Awarding Respondent's pension, profit sharing, retirement plan, I.R.A., 401(k) or other retirement fund as follows: 100% to Respondent OR Other (describe fully):

20.

Debts a. The debts are divided as follows. The person ordered to pay a debt shall hold the other person harmless from any responsibility for the debt.

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Debt Owed To:

To Be Paid By:

b. Each party is solely responsible for paying any other debts incurred solely by him or her and each party shall hold the other harmless from any responsibility for such separately incurred debts. 21. Name Change Neither party is requesting a name change. OR Changing Petitioner's name to:
First Middle Middle Last Last

Changing Respondent's name to:
First

22.

Paternity Questions Check only if applicable: The Husband does not have a parent ­ child relationship with a child or children named: , born to Wife during the marriage, and Husband is not the father. The issue of paternity of the unborn child of Wife is reserved.

23.

Other:

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24. 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 herein. awarded

25.

Petitioner and Respondent agree that after a Judgment and Decree has been entered herein, Petitioner may have a third party, age 18 or older, serve the Judgment and Decree upon Respondent by mailing it to Respondent's last known address by first class mail, postage prepaid. The parties agree that service by mail instead of personal service shall constitute proper service of the Judgment and Decree for all purposes. Petitioner is responsible for filing an Affidavit of Service of the Judgment of Decree in the court file.

26.

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 Maintenance and Child Support pursuant to, Minnesota Statutes § 518A.53; Change of Address or Residence; Cost of Living Increase of Maintenance and Support pursuant to Minnesota Statutes § 518A.75; Judgments for Unpaid Maintenance and Child Support pursuant to Minnesota Statutes § 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.

27.

The parties agree that the foregoing Stipulated Findings of Fact and Conclusions of Law incorporate the complete and full Marital Termination Agreement.

ACKNOWLEDGEMENT The undersigned parties affirm to the Court that the foregoing Conclusions of Law incorporate the parties' complete and full agreement for marital termination to resolve all issues in this dissolution case, and upon approval and entry by the court, shall constitute the judgment and decree for marriage

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dissolution for all purposes. Furthermore, the parties assert that the facts stated in the Findings of Fact are true and accurate, that each party has fully disclosed the nature and extent of his or her property, debts, and income, and that this agreement is based upon that full and fair disclosure. The parties ask the Court to enter judgment in strict conformity with the foregoing and, so long as the Court does so, the parties agree that this matter may proceed as by default. If the Court intends to deviate at all from the terms of the foregoing, each party shall be notified and given the opportunity to present all arguments concerning all issues in the dissolution case.

STATE OF MINNESOTA COUNTY OF _______________________)SS
(County where document is signed)

STATE OF MINNESOTA COUNTY OF_____________________)SS DATED: __________________________________ _________________________________________ Signature of Respondent
(Do NOT sign unless in presence of Notary Public)

DATED: ____________________________ ___________________________________ Signature of Petitioner
(Do NOT sign unless in presence of Notary Public)

Subscribed and sworn to before me this _____ day of _________________, _______
__________________________________________

Subscribed and sworn to before me this _____ day of _____________________, _________
__________________________________________________

Notary Public/Deputy Court Administrator Petitioner:

Notary Public/Deputy Court Administrator

is not represented by an attorney (Sign Petitioner's Waiver of Counsel) is represented by the following attorney: Attorney's Name:_________________________________ __________________ Attorney's ID #:________________ Telephone: ( )_____________________ Attorney's Address:__________________________________________________ City, State, Zip:___________________________________ _________________ is not represented by an attorney (Sign Respondent's Waiver of Counsel) is represented by the following attorney: Attorney's Name: ____________________________________________________ Attorney's ID #:_________________ Telephone: ( ) ___________________ Attorney's Address__________________________________________________ City, State, Zip: ___________________________________________________
By _______________________________________________

Respondent:

By _______________________________________

Attorney for Petitioner

Attorney for Respondent

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ORDER FOR JUDGMENT LET JUDGMENT BE ENTERED IMMEDIATELY. The foregoing facts were found by me after due hearing and the Order thereon is recommended. ________________________ District Court Referee Dated:_____________________ BY THE COURT

___________________________________ Judge of District Court Dated:_______________________________

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

PETITIONER'S WAIVER OF COUNSEL

I,

, know I have the right to be represented by a lawyer

of my choice. I hereby expressly waive that right and I freely and voluntarily sign the foregoing stipulation to terminate my marriage and resolve all issues in this marriage dissolution case. I understand that an attorney would be helpful in determining the issues contained in the foregoing stipulation; however, I specifically decline to retain independent counsel.

__________________________ Date

___________________________________________ Signature of Petitioner

RESPONDENT'S WAIVER OF COUNSEL

I, __________________________________ declare as follows: 1. I know I have the right to be represented by an attorney of my choice. I hereby expressly waive that right and I freely and voluntarily sign the foregoing stipulation to terminate my marriage and resolve all issues in this marriage dissolution case.

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2.

I understand that an attorney would be helpful in determining issues contained in the foregoing stipulation; however, I specifically decline to retain independent counsel.

3.

I hereby expressly waive any right to contest the agreements set forth in the foregoing stipulation and I waive the thirty (30) days period to answer.

4.

My spouse may proceed to judgment pursuant to the terms of said stipulation as if by default, and without further notice to me.

__________________________ Date

___________________________________________ Signature of Respondent

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