Free State of Minnesota - Minnesota

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

In re the Marriage of:

Petitioner and

Certificate of Dissolution
Minn.Stat. §518.148

Respondent 1. Petitioner's name is: 2. Petitioner's prior name(s) or other name(s) are: None OR .

First First

Middle Middle

Last Last

3. Respondent's name is: 4. Respondent's prior name(s) or other name(s) are: None OR

First First

Middle Middle

Last Last

5. The marriage of Petitioner and Respondent is dissolved. The date of the Judgment and Decree is: .

6. Name Changes in the Judgment and Decree: (Check all that apply)

None Petitioner's name is changed to:
First Middle Last

Respondent's name is changed to:
First Middle Last

DIV103

State

ENG

Rev 6/03-D

www.courts.state.mn.us/forms

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7. The parties have each child is:

living minor or dependent children together. The name of

8. Refer to "Form 11. Confidential Information Form" for social security numbers. (Per Minn. Gen. R. Prac. 313.01)

This Certificate of Dissolution is conclusive evidence of the facts recited herein.

Dated: Judge of District Court

DIV103

State

ENG

Rev 6/03-D

www.courts.state.mn.us/forms

Page 2 of 2