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

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

District Court
Dissolution with Children

In Re the Marriage of:
, Name of Husband (First, Middle, Last)

and

Joint Petition, Agreement, and Judgment and Decree for Marriage Dissolution With Children
.

Name of Wife (First, Middle, Last)

1.

Information about Husband: Full Name:
First Middle Last

Address:
Street Address Apt. No.

City

County

State

Zip Code

Date of Birth: __________________________
Month Day Year

Husband's former or other names:
(Or write "none)
First Middle Last

Husband's social security number is listed on Confidential Form 11.1 and submitted along with the Joint Petition. 2. Information about Wife: Full Name:
First Middle Last

Address:
Street Address Apt. No.

City

County

State

Zip Code

Date of Birth: __________________________
Month Day Year

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Wife's former or other names:
(Or write "none")
First Middle Last

First

Middle

Last

Wife's social security number is listed on Confidential Form 11.1 and submitted along with the Joint Petition. 3. Our Marriage Husband and Wife were married on: (month, day, year) in the City of of 4. 180 Day Requirement Husband has been living in Minnesota for the past six (6) months: Wife has been living in Minnesota for the past six (6) months: 5. Armed Forces Husband is an active duty member of the armed forces: YES NO YES YES NO NO , Country of , County of , State

If YES, has the member of the armed forces been stationed in Minnesota for the past six (6) months? YES NO YES NO

Wife is an active duty member of the armed forces:

If YES, has the member of the armed forces been stationed in Minnesota for the past six (6) months? 6. YES NO

Marriage Cannot be Saved There has been an irretrievable breakdown of our marriage relationship.

7.

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

YES

NO .

If YES , Husband and Wife are living together at this time because:

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8.

Other Proceedings a. A separate court case for dissolution, legal separation, annulment, custody, parenting time, or paternity has already been started by Husband or Wife in Minnesota or another state: YES NO. If YES, the type of court case is: County in the State of , and the outcome of the case .

and it was started in and the Court file number is is: Open Closed

Unknown or

b. Has a County started a Support case involving the Husband and the Wife or their children? YES NO. If YES, the case was started in and the Court file number is Dismissed Pending an Order for Support was

County in the State of . The case is issued. 9. Protection or Harassment Order

a. An Order for Protection or a Harassment/Restraining Order is in effect regarding Husband and Wife: Wife on
Month Day Year

YES

NO.

If YES, the Order protects:

Husband County

the child(ren). The Order was filed in , and the Court file number is

A copy of the Order is submitted along with this Joint Petition. b. If an Order for Protection is in effect, does the Order for Protection include a child support obligation? 10. Juvenile Court Case A Juvenile Court case (child protection, delinquency or foster care) involving husband's and wife's child(ren) has taken place in Minnesota or another state. If YES, the case is in and the Court file number is children involved in the Juvenile Court case is: YES NO YES NO

County in the State of _________________ . The name of the child or

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11.

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

a.

List all joint children born before the marriage or born or adopted during the

marriage. If there are no joint children, or if Wife is not currently pregnant, you are using the wrong form. Use Joint Petition, Agreement and Judgment and Decree Without Children. Full Name of Child Date of Birth Age Child Currently Lives With Husband Wife Both parents OR ________________________________
(write in name)

Husband Wife Both parents OR ________________________________
(write in name)

Husband Wife Both parents OR ________________________________
(write in name)

Husband Wife Both parents OR ________________________________
(write in name)

Husband Wife Both parents OR ______________________________
(write in name)

The social security number of the child(ren) is/are listed on Confidential Form 11.1 and submitted along with the Joint Petition. If a child is living with someone other than a parent, write the child's address below: Address:________________________________________________________________
Street Address Apt. No.

City

County

State

Zip Code

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

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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 : Child support may be ordered for a joint child over the age of 18 who
cannot support him/herself because of a physical or mental condition.

Is there an adult joint child born to or adopted by Husband and Wife who is not able to support himself or herself because of a physical or mental condition? YES NO

If YES, the full name, date of birth and age of each adult dependent is: Full Name of Dependent Date of Birth Age

The social security number of the adult dependent child(ren) is / are listed on Confidential Form 11.1 and submitted along with the Joint Petition. 13. Pregnancy Is wife pregnant? YES NO

If wife is pregnant answer (a) and (b): a. The date the baby is due is
Month Day Year

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

14.

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:

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Full Name of Child and Age

Date of Birth

Does Child Live with Husband? YES NO YES YES YES NO NO NO

Is Husband Court-Ordered to pay Child Support for this Child? YES NO YES YES YES 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 YES YES YES NO NO NO Is Wife Court-Ordered to pay Child Support for this Child? YES 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
Full Name of Child(ren)

If YES, submit a copy of the Order. The Order is for:

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(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: attach a copy of the Recognition of Parentage. If NO, why not? (iv) Has the Husband signed the "Husband's Non-Paternity Statement " for any of the children listed at (i) above? YES NO YES NO and

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: (check one)

Joint legal custody to both parents 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: Husband's parenting time with the joint child(ren) be: (check one) unsupervised supervised reserved Wife's parenting time with the joint child(ren) be: (check one) unsupervised supervised reserved

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

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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)

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

18.

Public Assistance: (Note: If either person is receiving public assistance from the State of Minnesota or
applies for it after this proceeding is started, notice of this marriage dissolution action must be given to the county's collections and support office. See Minnesota Statutes Section 518A.44)

a. Husband 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 $ Tribal TANF in the amount of $ per month per month

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General Assistance in the amount of $ Medical Assistance Child Care Assistance MinnesotaCare

per month

b. Wife 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 $ Tribal TANF in the amount of $ General Assistance in the amount of $ Medical Assistance Child Care Assistance MinnesotaCare per month per month per month

c. The joint children of the parties receive public assistance from the State of Minnesota: Yes No County. (Check all that apply): Tribal TANF MinnesotaCare

If YES, the assistance is from MFIP Medical Assistance

IV-E Foster Care

19.

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

a. Husband receives Supplemental Security Income (SSI): amount of $ per month. No

No

Yes in the

b. Wife receives Supplemental Security Income (SSI): of $ per month.

Yes in the amount

c. The joint child(ren) of the parties receive(s) Supplemental Security Income (SSI): No Yes in the amount of $ per month. What is the name of the

child receiving SSI? Husband's Employment a. Husband is employed: Yes No Husband is self-employed: Yes No Yes No

20.

b. Husband works at least 40 hours per week:

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

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

c. Current Employment: (if Husband currently has more than two jobs, use an attachment for the
additional jobs.) Name of Husband's Employer (If self-employed, list name and business address) Employer's Street Address

City

State

Zip Code

Name of Husband's Employer if self-employed, list name and business address) Employer's Street Address

City

State

Zip Code

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

1st Job hourly salary

2nd Job hourly salary

________________hours

________________hours

How much overtime pay does Husband receive per week on $_____________________ average?

$____________________

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Does Husband receive bonuses? Yes Yes No 1st Job No 2nd Job

If Yes, how much was received in bonuses last year? $_____________ How much does Husband expect to receive this year? $___________

If Yes, how much was received in bonuses last year? $_____________ How much does Husband expect to receive this year? $___________

21.

Husband'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 received Other income____________________________
List 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 Husband is court-ordered to pay for any nonjoint child(ren) $______________ per month Enter the amount of spousal maintenance Husband is court-ordered to pay to a current or former spouse $______________ per month

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Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Husband's retirement, disability, or other eligibility $______________ per month Which parent receives the payment for the child? Husband Wife 22. Living Expenses for the Family a. Husband and Wife and their child(ren) are still living together. Current monthly living expenses for the family total $ OR b. Husband and Wife are living separately. The monthly family living expenses before separation totaled $ . At this time, Husband's separate monthly .

living expenses total $____________, and Wife's monthly living expenses total $______________. Of the total current monthly living expenses for Husband, $_______________ amount is for expenses just for the child(ren) that live(s) with Husband. Of the total current monthly living expenses for Wife, $___________is for expenses just for the child(ren) that live(s) with Wife.

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 Husband's monthly living expense (stated at #22) include the special needs expenses for the child? YES NO c. Does Wife's monthly living expense (stated at #22) include the special needs expenses for the child? YES NO

24.

Wife's Employment a. Is Wife employed? YES NO Is Wife self-employed? YES NO

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b. Is Wife working at least 40 hours per week?

YES

NO

If Wife is unemployed or works less than 40 hours/week, answer these questions: i. Explain why Wife is not working or why Wife works less than 40 hours/week

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

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

Employer's Street Address

City

State

Zip Code

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

Employer's Street Address

City

State

Zip Code

Questions about Jobs Is Wife paid by the hour or salaried?

1st Job hourly salary

2nd Job hourly salary

What is the average number of hours Wife works per week? How much overtime pay does Wife receive per week on average?

________________hours

________________hours

$_____________________

$____________________

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Does Wife receive bonuses? Yes Yes No 1st Job No 2nd Job

If Yes, how much did Wife receive in bonuses last year? $____________________ How much does Wife expect to receive this year? $____________________

If Yes, how much did Wife receive in bonuses last year? $___________________ How much does Wife expect to receive this year? $___________________

25.

Wife's Income Source of Income Self Employment Income
Self Employment income means gross receipts minus costs of goods sold minus ordinary and necessary business expenses.

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

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 received 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 Wife is court-ordered to pay for any nonjoint child(ren)

$______________ per month

Enter the amount of spousal maintenance Wife is court-ordered to pay to a current or former spouse $______________ per month

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Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Wife's retirement, disability, or other eligibility $______________ per month Which parent receives the payment for the child? Husband Wife 26. Child Care Costs Are there child care costs for joint children because of work or school? If YES, a. How many of the joint children need child care? One Two Three ________ YES NO

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 for his per are are not

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

27.

Health Care Coverage a. Who receives Minnesota Care or Medical Assistance? Husband Wife Joint Children No one b. Does Husband have medical insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to c. i. Where does Husband get the medical insurance? through his 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

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iii. Who is currently covered by this medical insurance? Husband Wife All the joint children Some of the joint children:

Name the joint children who are covered_____________________________________

Nonjoint children covered c. Does Husband have dental insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to d. i. Where does Husband get the dental insurance? through his 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? Husband Wife All the joint children Some of the joint children:

Name the joint children who are covered____________________________________

Nonjoint children d. Does Wife have medical insurance? (other than MN Care or Medical Assistance) Yes No If No, skip to e. i. Where does Wife get the medical insurance? through 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? Husband Wife All the joint children Some of the joint children:

Name the joint children who are covered____________________________________

Nonjoint children

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

i. Where does Wife get the dental insurance? through 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? Husband Wife All the joint children Some of the joint children:

Name the joint children who are covered_____________________________________

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

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 entry of the judgment for divorce. Payment shall be through income withholding. This amount is based on the calculations from the child support guidelines worksheet, which is attached and incorporated into this Joint Petition. 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 entry of the judgment for divorce. Payment shall be through income withholding.

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This 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 Husband need spousal maintenance from Wife? YES NO

If YES, Husband is ______ years of age, Husband and Wife have been married for ______ years. Husband has the following education: _______________________________. Husband's gross monthly income totals $ _____________ . Husband's monthly expenses total $ , and Husband

is not able to maintain the standard of living established during the marriage because:

Wife has the ability to pay Husband $ maintenance.

per

month

for

spousal

b. Does Wife need spousal maintenance from Husband?

YES

NO

If YES, Wife is ______ years of age, Husband and Wife have been married for ____ years. Wife has the following education:___________________________________. Wife's gross monthly income totals $ _____________ , Wife's monthly expenses total $ , and Wife is not able to maintain the standard of living

established during the marriage because:

Husband has the ability to pay Wife $ 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

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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.

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 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 Joint Petition.

31. Other Findings

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AGREEMENT OF HUSBAND AND WIFE 1. We have made this agreement to settle once and for all what we owe to each other and what we can expect to receive from each other. Each of us states that nothing has been held back, and that we have honestly included everything we could think of in listing our assets (everything we own and that is owed to us) and our debts (everything we owe) and that we believe the other has been open and honest in writing this agreement. We will sign and exchange any papers that might be needed to complete this agreement before or after the divorce.
Legal Custody means which parent(s) have a say in the major decisions regarding the joint child(ren)'s life including education, religious upbringing and medical treatment.

2.

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 Husband both parties. Solely to Husband to both parties. Solely to Husband to both parties. Solely to Husband to both parties. Solely to Husband to both parties. 3. OR OR OR OR OR Solely to Wife OR Solely to Wife OR Solely to Wife OR Solely to Wife OR Solely to Wife OR Jointly to Jointly Jointly Jointly Jointly

Physical custody identifies which parent(s) will handle the routine daily care and control of the joint 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 Husband OR both parties. Solely to Husband OR to both parties. Solely to Husband OR to both parties. Solely to Wife OR Solely to Wife OR Solely to Wife OR Jointly to Jointly Jointly

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Solely to Husband OR to both parties. Solely to Husband OR to both parties. 4. Parenting Time a. Husband's parenting time shall be: b. Wife's parenting time shall be:

Solely to Wife OR Solely to Wife OR

Jointly Jointly

Unsupervised Unsupervised

Supervised

Reserved

Supervised

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:

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)

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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 Husband: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time 5.

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

Basic Support for the Joint Child(ren) (Fill in a or b) a. Husband Wife shall pay to Husband Wife $___________

per month starting on (date):___________________as the basic support obligation for the parties' joint child(ren). This amount is based on the

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calculations from the child support guidelines worksheet, which is attached and incorporated into this Joint Petition. Any past due amounts pursuant to a different court order of child support are still owed. This amount is a deviation from the basic support obligation under Minnesota laws, and 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 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 self-employed, send payments to Minnesota Child

Support Payment Center, P.O. Box 64306, St. Paul, MN 55164-0306. To start income withholding, Husband or Wife 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 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:

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a.

Husband

Wife 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 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. Husband Wife 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. Husband Wife 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 child(ren).

Ordering Dental Insurance as follows: a. Husband Wife 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. Husband Wife 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

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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:

7.

Uninsured and Unreimbursed Medical and Dental Expenses for the Joint Children a. Husband shall pay _________ % of the uninsured and/or unreimbursed medical and dental costs for the joint child(ren) of the parties, and Wife shall pay________% based on the percentage share of combined PICS (parental income for determining child support.) The parent who paid the bill must tell 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 of your percentage share. 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

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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

b. ____________________________(full name) shall provide

dental 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. 9. Child Care Support a. Husband shall pay $ and Wife shall pay $ per month for child care expenses, per month for child care expenses; OR

b. Reserving the issue of child care expenses.

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:

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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. Full disclosure of each party's financial 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.

Husband

Wife shall pay permanent spousal maintenance to the other party per month starting on (date):

in the amount of $

d.

Husband

Wife shall pay temporary spousal maintenance to the other party per month starting on (date): .

in the amount of $ and ending on (date):

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 self-employed, send payments to Minnesota Child Support Payment Center, P.O. Box 64306, St. Paul, MN 55164-0306. To start income withholding,

Husband or Wife must apply for income withholding only services at the Child Support office in their County and must send a copy of this Order to the Child Support office. Until income withholding starts, the person owing maintenance shall pay the amount directly to the spouse receiving it. OR

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maintenance shall be paid directly by the spouse owing the maintenance to the spouse receiving it, payable on the _____________day of each month.

11.

Real Estate Real estate includes a homestead, condominium, apartment building, vacant land, contract for deed interest, remainder interest, and more. Husband owns no real estate by himself or with anyone else. Wife owns no real estate by herself or with anyone else. Husband and/or Wife own real estate as described on the Real Estate Attachment(s). (Use a separate Real Estate Attachment sheet for each parcel of real estate. The Real Estate Attachment sheet(s) must be attached to this Joint Petition, even if Husband and Wife have no real estate.)

All Real Estate Attachments are incorporated into this Joint Petition, Agreement, Judgment and Decree and Husband and Wife agree that the real estate shall be awarded as stated on the Real Estate Attachment(s) in Attachment "C". Check one: There is one Real Estate Attachment; OR There are ______ Real Estate Attachments.

12.

Non-Marital Property
Non-marital Property means: (1) anything that you or your spouse owned before the marriage; (2) a gift, bequest, devise, or inheritance made by a third party to one but not to the other spouse; (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 (STOP: Property can be part nonmarital and part marital. Defining and valuing non-marital property can be complicated. If you have any concerns or questions, you should stop here and talk to an attorney.) (5) anything you or your spouse received after the valuation date set by the Court; or (6) anything defined as nonmarital property by a valid antenuptial contract.

a. Husband owns non-marital property: YES NO

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If YES, Husband and Wife agree that that the following property is Husband's nonmarital property and shall be awarded to Husband:

The total value of Husband's non-marital property is $

b. Wife owns non-marital property: YES NO If YES, Husband and Wife agree that the following property is Wife's non-marital property and shall be awarded to Wife:

The total value of Wife's non-marital property is $ 13. Division of Marital Property
Marital Property means almost anything that you or your spouse own that you or your spouse received during the marriage, even during the times that you and your spouse were separated. This includes real estate, boats, cabins, household goods, furniture, jewelry, and other things.

(See attached Asset Sheet listing all assets. The Asset Sheet must be attached to the Joint Petition, even if husband and wife have no assets.)

The Asset Sheet is incorporated into this Joint Petition, Agreement, Judgment and Decree and Husband and Wife agree to divide their marital property as listed by them in Attachment
"A".

14.

Division of Marital Debts
Marital Debts means debts incurred by you or your spouse during the marriage, even during the times that you and your spouse were separated. Do not include monthly expenses you pay in full each month, such as telephone and utilities.

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(See attached Debt Sheet listing all debts. The Debt Sheet must be attached to the Joint Petition, even if wife and husband have no debts.)

The Debt Sheet is incorporated into this Joint Petition, Agreement, Judgment and Decree and Husband and Wife agree to divide their marital debts as listed by them in Attachment "B".

15.

Name Change Neither party is requesting a name change. Changing Husband's name to:
First Middle Middle Last Last

Changing Wife's name to:
First

16.

Paternity Question 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.

17.

Other:

BASED UPON THE ABOVE INFORMATION, Husband and Wife request that the Court issue a final judgment and decree terminating our marriage and ordering the terms of this Agreement. READ and SIGN the Verification and Acknowledgments. STATE OF MINNESOTA COUNTY OF (County where documents signed) ) ) SS )

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Verification and Acknowledgments a. I have read this document. To the best of my knowledge, information and belief the information contained in this document is well grounded in fact and is warranted by existing law. I have not been determined by any Court in Minnesota or in any other State to be a frivolous litigant and I am not the subject of an Order precluding me from serving or filing this document. I am not serving or filing this document for any improper purpose, such as to harass the other party or to cause delay or needless increase in the cost of litigation or to commit a fraud on the Court. I understand that if I am not telling the truth or if I am misleading the Court or if I am serving or filing this document for an improper purpose, the Court can order me to pay money to the other party, including the reasonable expenses incurred by the other party because of the cost of serving or filing this document, Court costs, and reasonable attorney's fees. WAIVER (Rule 306.01(c)): 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 this Joint Petition and Agreement.

b.

c.

d.

e.

DATE:

DATE:

Signature of Husband (Sign only in presence of notary public) ( ) Daytime Telephone Number of Husband Sworn / affirmed to before me this Day of ,

Signature of Wife (Sign only in presence of notary public) ( ) Daytime Telephone Number of Wife Sworn / affirmed to before me this Day of , _____

______________________________ Notary Public

Notary Public

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HUSBAND'S ATTORNEY Husband is acting as his own attorney OR is represented by the following attorney:

WIFE'S ATTORNEY Wife is acting as her own attorney OR is represented by the following attorney:

Name

Name

Address

Address

City / State / Zip

City / State / Zip

Telephone

Telephone

Attorney Registration Number

Attorney Registration Number

(If public assistance is being provided to a party or joint child(ren), the public authority must sign off on this Joint Petition and Agreement.) The public authority responsible for the collection and enforcement of child support reviewed and agreed to the Joint Petition and Agreement of the above-named parties. DATE:

Name and Title

Attorney Registration No.

Address

City / State / Zip

Telephone

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COURT ORDER This case came before the Court without a hearing on the parties' Joint Petition for Dissolution of Marriage because both parties are represented by attorneys. The Court, having reviewed the file, makes the following Order: OR This proceeding for dissolution of marriage came before the undersigned judge of district court on the State of Minnesota. Husband (date) at did did not appear. Wife appeared as attorney for did (location) in did not appear.

Husband Husband

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

Wife Wife

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

1.

The parties' Joint Petition and Attachments contains the necessary facts and includes an agreement on all issues before the Court. The real estate, if any, and the personal property of the parties is hereby awarded according to the division set out in their foregoing Joint Petition, which is made part of this final judgment. Debts and liabilities of the parties must be paid as provided in their foregoing Joint Petition. Spousal maintenance, custody, parenting time, and child support are ordered as set out in the Joint Petition and Agreement. The parties are ordered to obey all of its provisions.

2.

The marriage between the parties is dissolved and the parties are single. Husband's
first

3.

Wife's name is changed to:
middle last

4.

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

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execute the necessary documents, a certified copy of the Judgment and Decree shall operate to transfer title as awarded herein.
5.

NOTICE: IF THE AGREEMENT OF THE PARTIES INCLUDES AN AWARD OF SPOUSAL MAINTENANCE AND / OR CHILD SUPPORT, Appendix A is incorporated and made a part of this final judgment. Appendix A contains, among other things, provisions regarding payments to the Public Agency pursuant to 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 Child 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.

General Rule of Practice 125 notwithstanding, 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 constitutes the Judgment of the Court.
_____________________________________________

Court Administrator Dated:

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Attachment "A" DIVISION OF ASSETS AND VALUE Husband's Name: Wife's Name: 1. We agree on how to divide our assets (everything we own and that is owed to us). 2. Each person shall receive as their own all assets in their column. Definitions: Current Fair Market Value is an estimate of the amount of money you could get if you sold the item to a stranger, such as through a newspaper advertisement. It does not mean what you paid for it originally, and it does not mean what it would cost you to replace it if you lost it. If you are still paying for an item, list it in husband's or wife's column at the present value. Present value means the current fair market value minus the amount you still owe. Who Gets the Item and What is the Value



DESCRIPTION OF ASSETS If you do not have the type of property described, enter a zero in the columns for Husband and Wife. To avoid confusion at a later date, describe each item as clearly as possible. For example, include the last 4 digits of account numbers (xxx2873), names of banks, & whose name is on the title or account, if applicable. List all property owned separately or together, no matter when it was acquired, except do not list the non-marital property described at #12 of the Joint Petition.

*Enter the current fair market value or present value of the item in the column of the person getting the item.



*HUSBAND

*WIFE



Cash on hand: Cash in banks/credit unions: (Name of bank, last 4 digits of account number, whose name is on the account)

$

$

$ $ $ $ $ Stocks/Bonds: $ $ $ $ $

$ $ $ $ $ $ $ $ $ $

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Notes (money owed to you in writing): $ $ Husband Money owed to you (not evidenced by a note): $ $ $ Business interests: (Name of business, who owns it) $ $ Automobiles: (Year, Make, Model) (Reminder: Use present value if you are still paying for the items.) $ $ $ $ Boats: $ $ Other vehicles: (Snowmobiles, 4-Wheelers, etc.) $ $ $ Retirement plans Profit Sharing or Pension: (Enter "present value". Contact plan
administrator for the present value. Include name of employer/group providing the plan, and type of plan.)

$ $ Wife $ $ $ $ $

$ $ $ $ $ $ $ $ $

$ $ 401(k), IRAs or other: (Enter current account balance, name of bank where funds are held, whose name is on the account.) $ $ $ Furniture & furnishings:
We have already divided the furniture and furnishings in a fair $ manner. (Enter in each spouses' column the total value of their share of the furniture and furnishings already divided); We agree to divide the furniture and furnishings as follows: (List items not included above.)

$ $ $ $ $ $

$ $ $ $

$ $ $ $

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$ $ $ $ Husband Collectibles & Jewelry: $ $ $ $ Life insurance: (cash surrender value) (Name of insurance company and
last 4 digits of policy number.)

$ $ $ $ Wife $ $ $ $ $ $

$ $ Sporting & entertainment & electronic equipment: stereo, guns, etc.) (TV, $ $ $ $ $ $ Real Estate:
Do Not List Here. Use Real Estate Attachment.

$ $ $ $ $ $

Other assets: $ $ $ $ Husband $ $ $ $ Wife $

Total Value of Property To Each Person:

(Excluding Real Estate, and any Non-Marital Property listed at Paragraph #12 of the Joint Petition.) $

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Attachment "B" DIVISION OF LIABILITIES/DEBTS Husband's Name: Wife's Name: Date we filled out this form: 1. We agree on how to divide our marital debts (debts we have incurred since our marriage date, either separately or together). 2. Each person shall pay as their own the debts listed in their column, and shall not ask the other person to pay these debts/bills. 3. We have listed all marital debts we know of on this Attachment. Any debts incurred by one of us alone and not listed on this Attachment shall be paid by the person whose name is on the debt/bill.


DESCRIPTION OF DEBT(S) If you do not have the type of debt described, enter a zero in the columns for Husband and Wife. To avoid confusion at a later date, describe each debt as clearly as possible. For example, state who the debt is owed to, whether husband's or wife's name is on the debt, and the last 4 digits of account numbers (xxx3094), if applicable. List all debts in husband's name alone and in wife's name alone and in both names together. Include debts incurred during the marriage and after separation. Do not include bills you pay in full each month.

*Write the current amount owed in the column of the person who will pay it.



*HUSBAND

*WIFE



Mortgages and loans on Real Estate:
Do not list here. Use the Real Estate Attachment.

Charge/credit card accounts: $ $ $ $ $ $ $ $ $ Auto loans: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

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Bank/credit union loans: $ $ $ $ Husband $ $ Student loans: $ $ $ $ Money you owe: (not evidenced by a note ) $ $ $ $ Judgments: $ $ $ Other debts: $ $ $ $ $ Husband Total Debts to be Paid by Each Person: (Excluding Real Estate mortgages and loans.) $ $ $ $ $ $ Wife $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Wife $ $

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Attachment "C" REAL ESTATE ATTACHMENT Fill out a separate Attachment for each parcel of real estate. 1. Real Estate belongs to: (List all owners)

2.

Street Address of the real estate is:

City The property is in

State County.

Zip Code

3.

Legal Description is:

(Use the full legal description from the deed.

If the legal

description is long, you may use an attachment. Type or print neatly.)

4.

Purchase date price: $ .

(month, day, year) and purchase

5.

Mortgages or loans: (Write "NONE" if there is no mortgage). 1st Mortgage: Amount currently owed $ and name of lender

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2nd Mortgage: Amount currently owed $

and name of lender

6.

Current Market Value of this property: $

7.

This property is the homestead:

Yes

No

AGREEMENT OF HUSBAND AND WIFE 1. All right, title, and interest of Husband and Wife in the real estate described above shall be awarded to: Husband Wife

2.

Husband and Wife also agree that: (Describe any liens in favor of husband or wife, or other agreements about the use, sale of, or award of the property. Attach additional pages if needed. If there are no other agreements, write "None".)

3.

The Mortgage(s) or Loan(s) described above shall be paid by starting on the following date: (write "NONE" if there is no mortgage or loan.)

Husband

Wife

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