Free Form 14 General Judgment of Dissolution - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN In the Matter of the Marriage of: ) ) ________________________________, ) Petitioner, ) ) ) and ) ) ________________________________, ) Respondent ) ) and ) ) ________________________________, ) Child who is at least 18 and under 21 years ) of age, unmarried and unemancipated. ) (ORS 107.108) )

Case No.

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP and MONEY AWARD

1. This matter came before the Court: On the motion and affidavit of Petitioner, the default of Respondent having been found. On the motion of Petitioner, the default of Respondent having been found, and Respondent being represented by a guardian ad litem or another person described in Rule 27. On the motion and affidavit of Petitioner, Respondent having filed a Waiver of Further Appearance. On the stipulations of the parties, as shown by the signatures below. The court has waived the 90 day waiting period based on the following: the parties have entered into a stipulated (agreed to) judgment, or other: At a hearing held , at which the following persons were present: Date) Petitioner Petitioner's attorney Respondent Respondent's attorney: 2. Findings. The Court considered the: Affidavit Affidavit and stipulations Evidence presented and found that: A. Irreconcilable differences have caused the irremediable breakdown of this marriage/domestic partnership. B. Spouses Only: Petitioner Respondent has/have been a resident of and domiciled in the state of Oregon continuously for six months immediately prior to the filing of the Petition for Dissolution of Marriage. ///
GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 1 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

Domestic Partnership Only: One or both of the parties to this case currently live in the county where this petition has been filed, or neither party currently resides in Oregon but the petition has been filed in the county where Petitioner or Respondent last resided. C. Children of the Marriage/Domestic Partnership. The following children were born to/ adopted by the parties before or during this marriage/domestic partnership (list name(s), date of birth(s) and age(s)): Name Date of Birth Age

Petitioner Respondent is not the father, or paternity has not been established, of the children (list names): born during the marriage/domestic partnership on the following date(s): Neither party is now pregnant. Petitioner Respondent is now pregnant. Petitioner Respondent is not the parent of the child/ren due (date). D. Child Custody Jurisdiction. (Check appropriate boxes) I. Oregon has jurisdiction under the Uniform Child Custody Jurisdiction and Enforcement Act to hear the custody parenting time issue because: Oregon is the child/ren's home state (i.e., the child/ren have lived here continuously for the six month period immediately before this case was filed). Other reason:

II. Oregon does not have jurisdiction under the Uniform Child Custody Jurisdiction Act because:

E. Child/ren Who Are At Least 18 and Under 21 Years of Age. (child/ren's name) is at least 18 and under 21 years of age, is unmarried and unemancipated and has: Waived further appearance in these proceedings. Signed and stipulated to the terms of judgment evidenced by the signature below. Fully participated in the proceedings and the judgment effectively binds him/her to the terms. NOW, THEREFORE, IT IS HEREBY ORDERED: The terms of this judgment are effective immediately. The marital/domestic partner status of the parties shall terminate on the date this judgment is signed by the judge.

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 2 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

1. Parenting Plan Custody of the child/ren is awarded as follows: Petitioner is awarded sole custody of the following child/ren (list names): Respondent is awarded sole custody of the following child/ren (list names): The parties have agreed to joint custody of the following child/ren (list names):

Petitioner Respondent should have parenting time with the child/ren as set forth in the attached Parenting Plan, labeled Exhibit ____, or Other:

Petitioner Respondent shall not have parenting time because this would endanger the health and safety of the child/ren. Parenting time shall be supervised by Any cost of the supervision shall be paid by Petitioner Respondent Other: Petitioner and Respondent shall each provide contact addresses and contact telephone numbers to the other and notify each other of any emergency circumstances or substantial changes in the child/ren's health. Neither parent shall move to a residence more than 60 miles further distant from the other parent without giving the other parent reasonable notice of the change of residence and providing a copy of such notice to the court, or the requirement of ORS 107.159 regarding notice of move is suspended for good cause found. 2. Child Support, including Cash Medical Support. Check either A or B below: (A) No child support shall be ordered at this time because: Child support in the amount of $ monthly has already been ordered and docketed with the County Circuit Court, case number Other reason: (B) Child support shall be paid by Petitioner to Respondent (or) Respondent to Petitioner beginning on the first or of the month following the date of the judgment and continuing on the same day of each month thereafter. The support for each child shall continue until the child reaches eighteen (18) years of age, or is otherwise emancipated, unless the child is a student attending school as defined by Oregon law, in which case support shall continue until the child reaches 21 years of age. Until further order, the total payment per month shall be $ for children. Cash Medical Support: Of the amount ordered above in paragraph 2B, $ is cash medical. The cash medical support amount ordered is in addition to any percentage of uninsured costs either of the parties is ordered to pay below in paragraph 4(3).

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 3 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

(Check if applicable) Neither Petitioner or Respondent have appropriate private or public health care coverage available for the parties' child/ren (see 4(3) below). Cash medical support is is not ordered and the court's findings in this regard are as follows:

Petitioner Respondent and/or Child/ren are eligible for public medical assistance and cannot be ordered to pay cash medical support. (Check if applicable) This order shall modify and replace the following existing order: (List court/agency and case no.) because the court finds that the existing order was issued by an Oregon court or agency, one of the parents or the child/ren receiving support under the order still resides in Oregon and circumstances have changed since this order was entered. 3. Child Support Calculation (check any that apply). The child support worksheet on which the support amount was calculated is labeled "Exhibit " and attached to and incorporated in this judgment. The support award does not deviate from the amount presumed correct under the guidelines set out in the Oregon Administrative Rules. The support amount presumed correct under the guidelines set out in Oregon Administrative Rules is $ . The support award deviates from this amount because this Court finds that application of the formula would be unjust or inappropriate in this case because of (check one or more that apply): Recurring medical expenses of Other 4. Health Care Coverage. (Check one.) A.) PRIVATE INSURANCE IS AVAILABLE Petitioner Respondent shall name the child/ren as beneficiaries of the following appropriate private health care coverage for the duration of the support obligation (describe type/s of coverage): B.) NO PRIVATE INSURANCE IS AVAILABLE NOW Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties' child/ren. 1.) Petitioner Respondent is ordered to apply to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 2.) Petitioner Respondent has already applied to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 3.) The child/ren are currently enrolled in public health care coverage. This coverage shall be maintained. 4.) Petitioner, Respondent Both Petitioner and Respondent are ordered to provide appropriate private health care coverage when such coverage becomes available to them through any source. /// ///
GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 4 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

C.) RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES Petitioner should pay % and Respondent should pay % of the uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is in addition to any cash medical support ordered above in paragraph 2 as part of the child support award. NOTICE ABOUT PERIODIC REVIEWS If you are receiving child support services through the Department of Justice pursuant to option (a) above, either parent may request that the Department of Justice/Division of Child Support review the amount of support ordered after three years from the date the order took effect or at any time upon a substantial change of 5. Payment of Child Support. circumstances. 5. Payment of Child Support Pursuant to ORS 25.378(1), an income withholding order shall be issued to enforce the child support obligation unless an exception is indicated below. Exceptions to withholding. Income withholding is not ordered at this time because there is no support arrearage, the paying parent has not previously been granted an exemption from withholding, and: The parents, and the State, if support rights are assigned, have agreed in writing to an alternative arrangement; or Good cause not to require withholding is found because there is proof of timely payment of previously-ordered support and income withholding would not be in the best interests of the child. All payments of child support shall be made (check either (a) or (b) below): (a) To the Oregon Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309 or by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). By petitioner's request, collection, accounting disbursement, and enforcement services of this obligation shall be through the State of Oregon's Department of Justice. (b) Pursuant to the above exception, directly to Petitioner's Respondent's checking or savings account. A receipt of deposit shall be kept by the parent paying support as proof of payment. A canceled check is also prima facie evidence that payment has been made. The person receiving support shall provide the paying parent with current deposit slips and/or bank name, account name and account number.

NOTICE OF INCOME WITHHOLDING NOTICE OF INCOME WITHHOLDING This child supportis enforceable by incomeincome withholdingORS 25.378 25.378 to 25.390, 25.414 to and order is enforceable by withholding under under ORS to 25.390, 25.414 to 25.372 This support order 25.372 and 25.375. shall occur immediately, whenever there is an arrearage an arrearage to the equal to 25.375. Withholding Withholding shall occur immediately, whenever there is at least equalat leastsupport the support payment for one month, obligated parent requests such withholding, or whenever or obligee payment for one month, whenever thewhenever the obligated parent requests such withholding, thewhenever the obligee requests withholding for The cause. The District Attorney or, as appropriate, the Division of requests withholding for good cause. goodDistrict Attorney or, as appropriate, the Division of Child Support of Child Support of Justice will assist Justice, will assist in securing such withholding. Exceptions the Department of the Department ofin securing such withholding. Exceptions may apply in some may apply in some circumstances. circumstances. 6. Dependents for Tax Purposes. Petitioner Respondent shall be entitled to claim the following child(ren) as dependent(s) for tax purposes beginning the year this judgment is entered (list names): , OR ///
GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 5 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

Other (specify):

7. The support obligations ordered in paragraphs 2 through 6 above shall continue until the child reaches 18years of age or is otherwise emancipated, or until the child reaches age 21, so long as the child is a student attending school, as defined by Oregon law. 8. Life Insurance Coverage for Child/ren. Petitioner Respondent shall obtain and maintain life insurance for the benefit of the parties' child/ren throughout the period of the support obligation if he/she is insurable. The coverage shall be in the amount of $ . NOTICE ABOUT PARENTING TIME AND CHILD SUPPORT NOTICE ABOUT PARENTING TIME AND CHILD SUPPORT The terms of child support and parenting time (visitation) are designed for the child's benefit and not the The terms of child support and parenting time (visitation) are designed for the child's benefit and not the parents' benefit. You must pay support even you are not receiving parenting time. You must comply with parents' benefit. You must pay support even ifif you are not receiving parenting time.You must comply with parenting time and visitation orders even you are not receiving child support. parenting time and visitation orders even ifif you are not receiving child support. Violation of of child support orders and visitation or parenting time orders is punishable by fine, imprisonment Violation child support orders and visitation or parenting time orders is punishable by fine, imprisonment or other penalties. or other penalties. Publicly funded help is is available to establish, enforce, and modify child support orders. Paternity Publicly funded help available to establish, enforce, and modify child support orders. Paternity establishment services are services are also available. local district attorney, the domestic relations court clerk, court establishment also available. Contact yourContact your local district attorney, the domestic relationsor the clerk, Department of Justice at 1-800-850-0228 or 503-378-5567 for information. or the Department of Justice at 1-800-850-0228 or 503-378-5567 for information. Publicly funded help may be available toto establish, enforce, and modify parenting time or visitation orders. Publicly funded help may be available establish, enforce, and modify parenting time or visitation orders. Forms are available enforce parenting time or visitation orders. Contact the domestic relations, civil court Forms are available toto enforce parenting time or visitation orders.Contact the domestic relations, civil court clerk or courthouse facilitator for information. clerk or courthouse facilitator for information. 9. Spousal Support and Life Insurance. No spousal support or spousal life insurance is ordered in this case. The terms indicated on the inserted Supplement to Judgment shall be in effect. 10. Real Property Distribution. Neither Petitioner nor Respondent has any interest in any real property located in this or in any other state. Petitioner Respondent has/have an interest in real property located at the address of This property shall be distributed as follows: Additional page labeled "Paragraph 10 - Real Property Distribution continued" attached. The legal description of the property is attached as "Exhibit " and incorporated into this Judgment. Petitioner Respondent shall be responsible for the preparation, signing and recording of a deed, transferring the real property as required by this judgment. Distribution of this property is not within the jurisdiction of this court. /// ///
GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 6 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

11. Personal Property Distribution (including motor vehicles). The Petitioner and Respondent have divided between them all personal effects, household goods and other personal property they own separately or together, and each shall be awarded those items now in their possession. The Petitioner is awarded the following personal property:

Additional page labeled "Paragraph 11 - Petitioner's Personal Property Distribution continued" attached. The Petitioner is awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred compensation plan, and/or stock option plan held by Petitioner's current or past employer, free of any interest in the Respondent. The Respondent is awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred compensation plan, and/or stock option plan held by Respondent's current or past employer, free of any interest in the Petitioner. The Respondent is awarded the following personal property:

Additional page labeled "Paragraph 11 - Respondent's Personal Property Distribution continued" attached. 12. Distribution of Debts. The debts shall be paid as follows: Name of Creditor (who money is owed to) What debt is for Amount Who shall pay (Petitioner or Respondent)

Additional page attached, labeled "Paragraph 12 - Distribution of Debts continued". Each party shall be responsible for the payment of all debts incurred by him/her individually since the date of the separation; all debts which are distributed to him/her by the court; and all debts which are secured by property distributed to that party. Also, if any creditor asks the spouse/domestic partner not responsible for a debt to pay all or a portion of it, and s/he does so, the spouse/domestic partner responsible for that debt shall reimburse the other spouse/domestic partner for any monies s/he paid to the creditor after the date this judgment was entered. The date of separation (when you began living apart) was: /// /// ///
GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 7 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

.

13. Transfer of Property and Debts. Within thirty (30) days of the date of this judgment, each party shall execute, acknowledge and deliver whatever documents are necessary to accomplish the distribution of debts and property ordered by the court. The judgment shall operate to convey title to the party awarded the property if the other party fails to comply with this requirement. 14. Former Name. Petitioner's Respondent's former name of 15. Additional Provisions: Additional page attached labeled "Paragraph 15 - Additional Provisions continued". 16. Court Costs and Fees. A. Deferred Costs and Fees Any court costs and service fees (if service was completed by the Sheriff) that were deferred (required to be paid at a later date) by the court shall be paid by: Petitioner Respondent. Both parties equally Other: . B. Costs and Fees Paid by the Parties Each party shall be responsible for paying his/her own court costs and service fees for this case. To be paid by both parties equally Petitioner Respondent shall reimburse the other spouse for his/her court costs and service fees for this case. Other: . Judgment shall be entered according to the cost and fee allocation listed above. 17. Information Required by ORS 25.020 and ORS 107.085. Based on a finding that the health, safety, or liberty of Petitioner Respondent or a child, , would unreasonably be put at risk by disclosure of the following information, Petitioner Respondent has been allowed not to disclose this information. Otherwise: Petitioner Full Name Former Legal Name(s) Age Address or Contact Address Telephone Number Respondent

is restored.

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 8 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

Social Security Number Drivers License Number Employer Name Employer Address Employer Telephone

Do not list. Provided by UTCR 2.100 Affidavit

Do not list. Provided by UTCR 2.100 Affidavit

Additional page labeled "Paragraph 17 - Required Information continued" attached. Both parties shall inform the Court and the Department of Justice (P.O. Box 14506, Salem, Oregon 97309) in writing of any change in the above information required by ORS 25.020 within ten (10) days of such change, unless a finding of unreasonable risk has been made in this case. If the court has ordered that a party be allowed not to disclose information by means of this Judgment in Paragraph 17 above, the Department of Justice or the District Attorney shall not disclose the information in the preceding section to the other parent. Date of marriage/domestic partnership: Place of marriage/domestic partnership: 18. Money Award. Child Support Obligation included not included. Spousal Support included not included. Additional information required PETITIONER by ORS 18.042 Full Name Address or Contact Address Attorney's Name, Telephone Number and Address (if applicable) Date of Birth Driver's License Number and State of Issuance The following information is to be provided by any party entitled to receive a money award (a "judgment creditor") as listed in this Judgment. Others Entitled to Portions of Judgment Payable to PETITIONER The following person(s) or public bod(ies) are known by Petitioner to be entitled to a portion of a payment made on the judgment (other than Petitioner's attorney): None or . .

RESPONDENT

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 9 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

Others Entitled to Portions of Judgment Payable to RESPONDENT Type of Judgment Child Support Award

The following person(s) or public bod(ies) are known by Respondent to be entitled to a portion of a payment made on the judgment (other than the Respondent's attorney): None or

Amount of Judgment WHO PAYS Petitioner Respondent WHO RECEIVES Petitioner Respondent $ Other: Other: the judgment per month or , starting on the first day or of the month following the date of

Of this Child Support Award, $ ________________ constitutes "cash medical support" 1. $ per month or Other: , starting on the first day or Other: of the month following the date of the judgment, lasting until (date), or the death of either party, whichever comes first; or 2. A lump sum payment of $ by (date): to be paid

Spousal Support Award

WHO PAYS Petitioner Respondent

WHO RECEIVES Petitioner Respondent

SPOUSAL SUPPORT PAYMENTS ARE TAXABLE TO THE OBLIGEE SPOUSE AND DEDUCTIBLE TO THE OBLIGOR SPOUSE. ALL PAYMENTS TERMINATE UPON THE DEATH OF EITHER PARTY. Property Division WHO PAYS 1. $ per month, starting on the (if applicable) Petitioner first day or Other: of the month following the date of the Respondent judgment until the total amount of $ is paid in WHO RECEIVES full; or Petitioner Respondent 2. A lump sum payment of $ to be paid by: (date). Prejudgment WHO PAYS Interest Petitioner (Note: ORS Respondent 21.607(1) $ WHO RECEIVES disallows interest Petitioner on fees that have Respondent been deferred.)

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 10 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

Postjudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.)

WHO PAYS Petitioner Respondent

Nine percent ( 9 %) per annum simple interest on the unpaid balance of the total judgment amount(s) of $ . Interest accrues from the date the judgment is entered and continues until fully paid.

WHO RECEIVES Petitioner Respondent WHO PAYS Petitioner Respondent WHO RECEIVES Petitioner Respondent

Accrued Arrears (if any, on judgments to be paid on a periodic basis)

1. $ per month, starting on the first day or Other: of the month following the date of the judgment until the total amount of $ is paid in full; or 2. A lump sum payment of $ to be paid by: (date).

Costs and Service Expenses (e.g., filing fees, hearing fees, trial fees, process fees)

WHO PAYS Petitioner Respondent $ WHO RECEIVES Petitioner Respondent

Attorneys Fees (if any)

WHO PAYS Petitioner Respondent $ WHO RECEIVES Petitioner Respondent

DATED this ________ day of ________________________________, 20______.

_______________________________________________ Circuit Court Judge _______________________________________________ Print Name
GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; and MONEY AWARD - Page 11 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)

All parties have agreed (stipulated) to the terms of this judgment

Petitioner, Signature

Respondent, Signature

APPLICATION FOR CHILD SUPPORT PROGRAM SERVICES: By signing below, I apply for child support services from the Child Support Program(CSP). (Note: If you never received TANF, tribal TANF or AFDC in any state, an annual $25 fee will apply if over $500 is collected and distributed to the family each year.) Petitioner Signature

Date

Respondent Signature

Date

If applicable, child who is at least 18 and under 21 years of age, has agreed (stipulated to the terms of this judgment): Child, Signature
State of County of ) ) , 20 , (date)

This instrument was acknowledged before me on by

(name of person(s)).

Notary Public for My Commission Expires:

/Court Clerk

Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to for assistance in preparing this form. Submitted by:

Petitioner Respondent, Signature
Address or Contact Address
I certify that this is a true copy: ______________________________ Petitioner Respondent, Signature

Print Name

City, State, Zip

Telephone or Contact Telephone

GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; AND MONEY AWARD - Page 12 of 12
Disso-1B: Form 14 General Judgment with Children 1 2008 states version.doc (1/08)