State of Minnesota District Court Judicial District: Court File Number: Assigned Judge: Case Type: County of Dissolution without Children In Re the Marriage of: Name of Petitioner (first, middle, last) Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree (Gen. R. Prac. Rule 308.04) and Name of Respondent (first, middle, last) ------------------------------------------------------------------------------------------------------------------------------A. This proceeding for dissolution of marriage came before the undersigned judge of district court on _____________________________(date) at _____________________________(location) State of Minnesota. Petitioner did did not appear. Respondent did in the did not appear. _______________________________ appeared as attorney for _____________________. B. is NOT represented by an attorney OR Petitioner C. Petitioner is represented by the following attorney: _________________________________ . is NOT represented by an attorney OR Respondent D. Respondent is represented by the following attorney: _______________________________ . Service of the Summons and Petition for Dissolution of Marriage: Respondent was personally served on _________________________________, ___________, OR Respondent signed an Admission of Service on ___________________________, ___________, OR Respondent was served by alternate means as ordered by the court as follows: By mailing the Summons and Petition to Respondent at the address(es) stated in the Order for Service by Alternate Means on this date:___________________________________________ By publication of the Summons in _______________________________________ newspaper for 3 consecutive weeks, once each week, on the following 3 dates: ____________________ , ______________________________________________, and ________________________ . E. Petitioner was served with an Answer and Counter-Petition: YES NO If YES, Petitioner was served with the Answer and Counter-Petition on ________________, ______. Month Day Year F. Petitioner and Respondent have reached an agreement for marital termination resolving all issues in this case. Petitioner prepared the Stipulated Findings of Fact, Conclusions of Law, Order for Judgment and Judgment and Decree and incorporated the stipulated facts and terms of the parties’ DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 1 of 27 American LegalNet, Inc. www.FormsWorkFlow.com agreement. Respondent and Petitioner have signed an Acknowledgement regarding this agreement, which is included in this document. Findings of Fact 1. Information about Petitioner Full Name: _______________________________________________________________________ First Middle Last Address where you live: Street Address Apt. No. _______ City County State Zip Code Mailing address: Same as above address OR ________________________________________________________________________ Street Address Apt. No. _______ City County State Date of Birth: ________________________ Month Day Petitioner is the Zip Code Husband Wife. Year List all of Petitioner’s former or other names or write “None”: First Last First 2. Middle Middle Last Information about Respondent Full Name: First Middle Last Address where Respondent lives Street Address Apt. No. ________________________________________________________________________________ City DIV406 State County ENG Rev 4/09 State www.mncourts.gov/forms Zip Code Page 2 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Mailing address: Same as above address OR ________________________________________________________________________ Street Address Apt. No. _______ City County State Zip Code Respondent’s Date of Birth: ________________________ Month Day Year List all of Respondent’s former or other names or write “None”: First Last First 3. Middle Middle Last 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? 5. YES YES NO NO Armed Forces Is Petitioner an active duty member of the armed forces? 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 State ENG Rev 4/09 www.mncourts.gov/forms NO NO If YES, has Respondent been stationed in Minnesota for the past (6) months? DIV406 YES YES NO Page 3 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 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? YES NO If NO, the date of separation was: . Month Day Year If YES, Petitioner and Respondent are living together because: 8. Other Proceedings Has a separate court case for marriage dissolution, legal separation, or annulment already been started by Petitioner or Respondent in Minnesota or elsewhere? YES type of court case is: NO If YES, the , and it was started in ________________________ County in the State of ____________________ and the Court file number is Open 9. , and the status or outcome of the case is: Closed or Protection or Harassment Order Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and Respondent? YES NO If YES: The Order protects: and the Order was filed in State on 10. Petitioner Respondent County in date, and the Court file number is . Children “Minor” children are under age 18, or under age 20 but still in high school. a. Do Petitioner and Respondent have minor children together? YES NO b. Do Petitioner and Respondent have any adult dependent children who are not able to support DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 4 of 27 American LegalNet, Inc. www.FormsWorkFlow.com themselves because of a physical or mental condition? YES NO c. Has Wife given birth, since marrying Husband, to a child who is not Husband’s child? YES NO If you answered NO to c, skip to d. If YES, continue below: i. Fill in the information for all children born to Wife since marrying Husband, who are not Husband’s biological children. Full Name of Child Date of Birth Age ii. Is there a Court Order naming someone other than the Husband as the father of a child(ren) listed at i? YES NO If YES, fill in: Full Name of Child Date of Court Order County/State of Order Court Case No. iii. Have the Wife and biological Father signed a Minnesota Recognition of Parentage (ROP) for any of the children listed in (i) above? YES NO If YES, state the full name of the child: ______________________and attach a certified copy of the Recognition of Parentage, if not attached to the Petition. Has the Husband signed the “Husband’s Non-Paternity Statement” for any of the children listed at (i) above? YES NO If YES, state the name of the child: and attach a certified copy of the “Husband’s Non-Paternity Statement,” if not attached to the Petition. (For each minor child listed at c.(i.) there should be a paternity court order OR the Recognition of Parentage and Non-Paternity Statement to use this Dissolution Without Children form.) d. The Wife in this marriage is is not now pregnant. (If the Wife is pregnant use Marriage Dissolution With Children form.) DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 5 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 11. Public Assistance/Medical Assistance Note: If either party is receiving public assistance from the State of Minnesota or applies for it after this proceeding is started, the Petitioner should give notice of this marriage dissolution action to the Support and Collections office for the county paying the assistance. a. Petitioner receives public assistance from the State of Minnesota: YES NO If YES, the assistance is from _______________________County. (Check all that apply): MFIP Tribal TANF Minnesota Care General Assistance Child Care Assistance 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 Tribal TANF Minnesota Care 12. General Assistance Child Care Assistance Medical Assistance Supplemental Security Income (SSI) Supplemental Security Income (SSI) is a Federal income supplement program. It is available to low-income people if they are over age 65, or blind, or disabled. a. Petitioner receives Supplemental Security Income: NO YES in the amount of $____________ per month. b. Respondent receives Supplemental Security Income: NO YES in the amount of $____________ per month. 13. Petitioner’s Employment a. Is Petitioner employed? YES NO Is Petitioner Self-Employed? YES NO b. Name and address of Petitioner’s employer. (If Petitioner has more than one job, list the Name and Address of each employer.) ____________________________________________________________________________ Name of Petitioner’s Employer (If Self-Employed, list name and business address) ____________________________________________________________________________ Employer’s Street Address ____________________________________________________________________________ City State Zip Code Name of Petitioner’s Employer (If Self-Employed, list name and business address) DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 6 of 27 American LegalNet, Inc. www.FormsWorkFlow.com ____________________________________________________________________________ Employer’s Street Address ____________________________________________________________________________ City State Zip Code Petitioner’s Gross Income 14. The Income questions ask for monthly income. If you are paid weekly, multiply your weekly income by 4.33 to get monthly income. If you are paid every two weeks, multiply by 2.17 to get monthly income. If you are paid twice a month, multiply by 2. Source of Income Amount per month (or zero) before taxes and deductions Self Employment Income $________________per month Self Employment income means gross receipts minus cost of goods sold minus ordinary and necessary business expenses. Use monthly average. Income from all jobs $________________ per month Commissions from all jobs $________________ per month Unemployment benefits $________________ per month Social Security Retirement, Survivors or Disability Income $________________ per month Investments or Rental Income $________________ per month Annuity payments $________________ per month Pension or Disability from work or military $________________ per month Worker’s Compensation $________________ per month Court-ordered spousal maintenance you receive $________________ per month Other ____________________ $________________ per month Identify Source Total gross income $ _______________ per month Does Petitioner receive child support payments? YES NO If YES, Petitioner receives child support payments from ____________________________(name(s) of payor(s)) in the total amount of $_________________per month. 15. Respondent’s Employment Is Respondent employed? DIV406 State ENG Rev 4/09 YES NO Is Respondent Self-Employed? www.mncourts.gov/forms YES NO Page 7 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Name and address of Respondent’s employer. (If Respondent has more than one job, list the Name and Address of each employer.) ____________________________________________________________________________ Name of Respondent’s Employer (If Self-Employed list name and business address) ____________________________________________________________________________ Employer’s Street Address ____________________________________________________________________________ City State Zip Code ___________________________________________________________________________ Name of Respondent’s Employer (If Self-Employed list name and business address) ____________________________________________________________________________ Employer’s Street Address City State Zip Code Respondent’s Gross Income 16. The Income questions ask for monthly income. If you are paid weekly, multiply your weekly income by 4.33 to get monthly income. If you are paid every two weeks, multiply by 2.17 to get monthly income. If you are paid twice a month, multiply by 2. Source of Income Amount per month (or zero) before taxes and deductions Self Employment Income $________________per month Self Employment income means gross receipts minus cost of goods sold minus ordinary and necessary business expenses. Use monthly average. Income from all jobs $________________ per month Commissions from all jobs $________________ per month Unemployment benefits $________________ per month Social Security (SSDI or RSDI) $________________ per month Investments or Rental Income $________________ per month Annuity payments $________________ per month Pension or Disability from work or military $________________ per month Worker’s Compensation $________________ per month Court-ordered spousal maintenance you receive $________________ per month Other ____________________ $________________ per month Identify Source Total gross income DIV406 State ENG Rev 4/09 $ _______________ per month www.mncourts.gov/forms Page 8 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Does Respondent receive child support payments? YES NO If YES, Respondent receives child support payments from ____________________________(name(s) of payor(s)) in the total amount of $_________________per month. 17. Medical / Dental Insurance a. Does Petitioner have insurance coverage through his/her employment? Medical: YES NO Dental: If YES, this medical insurance covers: covers: Petitioner YES Petitioner NO Respondent and this dental insurance Respondent b. Does Respondent have insurance coverage through his/her employment? Medical: YES NO Dental: If YES, this medical insurance covers: covers: Petitioner YES Petitioner NO Respondent and this dental insurance Respondent c. Does Petitioner receive Medical Assistance or Minnesota Care through the State of Minnesota? YES NO d. Does Respondent receive Medical Assistance or Minnesota Care through the State of Minnesota? 18. YES NO Spousal Maintenance Spousal Maintenance is money paid by one spouse to the other for living expenses. Check only one box: Petitioner and Respondent do not need spousal maintenance at this time, or in the future. 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 agrees 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. DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 9 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Husband or Wife may need spousal maintenance in the future. The court should reserve maintenance to allow either party to ask for spousal maintenance in the future because: (explain why you want to do this) Petitioner needs spousal maintenance from Respondent now. Petitioner is __________years of age, Petitioner and Respondent have been married for _________years. Petitioner has the following education:_________________________________________________. Petitioner’s gross monthly income totals $__________________. Petitioner’s monthly expenses total $______________ and Petitioner is not able to maintain the standard of living established during the marriage because: _______________________________________________________ Respondent has the ability to pay Petitioner $_____________per month for spousal maintenance. Respondent needs spousal maintenance from Petitioner now. Respondent is __________years of age, Petitioner and Respondent have been married for _________years. Respondent has the following education:_____________________________________________. Respondent’s gross monthly income totals $______________. Respondent’s monthly expenses total $________________, and Respondent is not able to maintain the standard of living established during the marriage because: _______________________________________ . Petitioner has the ability to pay Respondent $_____________per month for spousal maintenance. 19. Vehicles Vehicles are cars, trucks, boats, motorcycles, snowmobiles, personal watercraft, all terrain vehicles etc. owned by husband or wife together or separately, including vehicles purchased after separation: Does Petitioner own a vehicle? YES NO Does Respondent own a vehicle? YES NO List all vehicles owned by husband or wife together or separately: Type of Vehicle (car, boat, truck etc.) Year/Make/ Name(s) on Model Value Title State ENG Rev 4/09 Monthly Payment $ DIV406 Balance Owed www.mncourts.gov/forms $ $ Page 10 of 27 American LegalNet, Inc. www.FormsWorkFlow.com $ $ $ $ $ $ 20. $ $ $ Marital Property Marital property means almost anything that you or your spouse now own that was received or bought during the marriage, even during the times you were separated. Marital Property includes household goods, furniture, jewelry, boats, real estate and other things. Marital property does not include a gift or inheritance received by one spouse alone. Has the marital property been divided between Petitioner and Respondent to their satisfaction? YES NO If NO, Petitioner requests the following marital property: _______________________________________________________________________________ If NO, Respondent requests the following marital property: _________________________________________________________________________ 21. Non-Marital Property Non-marital property means: (1) anything that you or your spouse owned before the marriage; (2) anything that you or your spouse received as a gift, bequest, devise, or inheritance, to you or your spouse alone; (3) anything that you or your spouse got in trade or in exchange for your nonmarital property; (4) anything that is an increase in the value of non-marital property; (5) anything you or your spouse received after the valuation date set by the court; or (6) anything defined as non-marital property by a valid antenuptial contract. a. Does Petitioner have non-marital property? YES NO If YES, list Petitioner’s non-marital property: . b. Does Respondent have non-marital property? YES NO If YES, list Respondent’s non-marital property: ___________________________________________________________________________. DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 11 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Cash & Accounts – Not including Pension and Employer-Funded Retirement Accounts 22. Does Petitioner have money in banks, savings, cash or investments? YES NO Does Respondent have money in banks, savings, cash or investments? YES NO If YES, a. List all accounts owned by you alone, your spouse alone, or owned by both of you jointly including those opened after separation. “Type of account” means checking, savings, money market accounts, certificates of deposit, stocks, bonds, stock options, mutual funds, savings bonds, and Treasury Bills, etc. Do not include Pension or Employer-Funded Retirement Accounts, which are listed at #26. Financial Type of Account Account # Amount (name on account) Last 4 digits only Institution Belongs to: 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 $ 23. Business Interest Does Petitioner have an interest in a business? YES NO Does Respondent have an interest in a business? YES NO If YES, the name of the business is ____________________________, the address is _______________________________________________________________________________ and the value is $________________. How did you arrive at this value? DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 12 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 24. Manufactured Home Does Petitioner own a manufactured home? YES NO Does Respondent own a manufactured home? YES NO If either Petitioner or Respondent own a manufactured home, together or separately, complete the following information: a. Address of the manufactured home: in the city of , 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. What was the purchase price? $ f. 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 25. 25. Real Property - Land, Buildings, Contracts for Deed All real property now owned by Petitioner or Respondent together or separately must be listed. Include real property acquired before the marriage, during the marriage, and after separation. a. Do Petitioner and Respondent jointly own real property? YES NO b. Does Petitioner own real property solely in his/her own name or with someone other than Respondent? DIV406 State YES ENG NO Rev 4/09 www.mncourts.gov/forms Page 13 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Does Respondent own real property solely in his/her own name or with someone other than Petitioner? YES NO How many properties are owned by you and your spouse in total? Three None One Two _______ If you or your spouse own real property, separately or together, complete the following information about the property. If there is more than one piece of real property, photocopy and complete a Real Property Information page for each piece of property. Staple the additional sheets to the Stipulated Findings of Fact and label each sheet "Attachment to Stipulated Findings of Fact of ____________________(your names)" Real Property Information 1. Real Estate belongs to: (List full names of all owners)_____________________________________ ________________________________________________________________________________ 2. Legal Description is: (The full legal description must be included. Copy the legal description from the deed. Do not use the property tax statement legal description. If the legal description is long, you may use an attachment. Type or print neatly.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Street Address of the real property is: ________________________________________________________________________ _ City______________________________________State______________Zip Code______________ The property is in_____________________________________County. 4. Purchase date_________________(month , day, year) and purchase price:$ 5. Mortgages or loans: (List all mortgages and loans on the property) There are no mortgages or loans on this property. 1st Mortgage: Amount currently owed $ and name of lender 2nd Mortgage: DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 14 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Amount currently owed $ and name of lender Other mortgages or loans: 6. Current Market Value of this property: $___________________________________ How did you arrive at this value? 7. This property is the homestead: _______Yes 26. _________No Retirement Plans Does Petitioner have a retirement account? (IRA, 401(k), 403(b) or other) YES NO If YES: a) The account number is: (last 4 digits only) b) The name of the bank that has the account is: c) The current account balance is: Has Petitioner, or Petitioner’s past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Petitioner? YES NO If YES: a) The name of the plan is:____________________________________________________ b) The employer, union or group providing the plan is: c) The date Petitioner began working at the job or joined the union or group plan is: d) The type of plan is: (e.g. defined benefit, defined contribution) e) The present value of the pension or plan is: Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other) YES NO If YES: a) The account number is: (last 4 digits only) DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 15 of 27 American LegalNet, Inc. www.FormsWorkFlow.com b) The name of the bank that has the account is: c) The current account balance is: Has Respondent, or Respondent’s past or present employer, union, or other group, paid money into a pension, profit sharing, or other retirement plan for Respondent? YES NO 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: ___________________________________ 27. Debts Does Petitioner have debt? YES NO Does Respondent have debt? YES NO If YES, list debts in your name, your spouse’s name and in both names jointly. Include unpaid debts from before the marriage date, during the marriage, and after separation. Fill in all information completely and attach another sheet of paper if necessary. Money is owed to: Money was used Whose Name is on the Account for: and When was the Debt Incurred? Name Date Balance Owed Monthly Payment $ $ State ENG Rev 4/09 www.mncourts.gov/forms $ $ DIV406 $ $ Page 16 of 27 American LegalNet, Inc. www.FormsWorkFlow.com $ $ $ $ $ $ $ $ 28. $ $ Total Debt $ $ $ $ $ $ Name Change a. Neither person wants to change his/her name. b. Wife Husband wants to change his/her name to: (full name, not initials) first middle last This name change request is made with no intent to defraud or mislead anyone: The person requesting the name change has been convicted of a felony: True YES False. 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 Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree. 29. Other Findings _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 17 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 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. Medical and Dental Insurance for the Parties a. Each party to provide for his or her own b. medical dental insurance. ____________________________(full name) shall provide medical 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. 3. 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. Full disclosure of each party’s financial circumstances has occurred. DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 18 of 27 American LegalNet, Inc. www.FormsWorkFlow.com b. Maintenance is reserved because: . Either party can ask the court to order the payment of spousal maintenance in the future by filing a Motion stating a change in circumstances. c. Petitioner Respondent shall pay permanent spousal maintenance to the other party in the amount of $ _________ per month starting on (date):________________________. Any past due amounts are still owed. d. Petitioner Respondent shall pay temporary spousal maintenance to the other party in the amount of $ _________ per month starting on (date): __________________________ and ending:________________________________________________________________. Any past due amounts are still owed. The monthly amount of permanent or temporary spousal maintenance shall be: subject to income withholding from the payor’s income, regardless of source, by his or her employer, trustee, or other payor of funds and mailed to: Minnesota Child Support Payment Center, P.O. Box 64326, St. Paul, MN 55164-0326. If the person paying spousal support is selfemployed, send payments to Minnesota Child Support Payment Center, P.O.Box 64306, St. Paul, MN 55164-0306. To start income withholding, Petitioner or Respondent must apply for income withholding at the Child Support Office in their county. Until income withholding starts, the person owing maintenance shall pay the amount directly to the spouse receiving it. OR Maintenance shall be paid directly by the spouse owing the maintenance to the spouse receiving it, payable on the ____________________day of each month. 4. Vehicles Awarding the vehicles as follows and ordering the party receiving the vehicles to pay for any loans or insurance for such vehicle: Year / Make / Model DIV406 State ENG Rev 4/09 Awarded to: www.mncourts.gov/forms Page 19 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 5. Marital Property The parties’ marital property, household goods, furniture and furnishings are awarded: a. As currently divided OR b. As follows (add pages if necessary): To Petitioner: To Respondent: 6. Non-Marital Property The parties’ non-marital property is awarded: a. As currently divided OR b. As follows (add pages if necessary): To Petitioner: To Respondent: 7. Cash and Accounts a. Awarding the savings and investments as follows: Institution Type of Account Account # Amount Awarded to (Last 4 digits only) XX XX State ENG Rev 4/09 $ XX DIV406 $ $ www.mncourts.gov/forms Page 20 of 27 American LegalNet, Inc. www.FormsWorkFlow.com XX XX $ XX b. $ $ Awarding any cash not included in a. above to the party who currently has the cash OR Awarding the cash as follows: 8. Business None OR Awarding the parties’ business as follows: ___________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 9. Manufactured Home None OR Awarding the manufactured home located at : street address city to state Petitioner Respondent. The debt on the manufactured home owed to: shall be paid by 10. Petitioner Respondent. 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 , County of ___________________________, State of , which has the following legal description: ______________ _______________________________________________________________________________ _______________________________________________________________________________ DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 21 of 27 American LegalNet, Inc. www.FormsWorkFlow.com with the following mortgages and loans to be paid, after the divorce is final, by Petitioner Respondent: 1st Mortgage: Amount currently owed: $ and name of lender: 2nd Mortgage: Amount currently owed: $ and name of lender: and subject to the following liens or other agreements: A lien in favor of Petitioner Respondent in the amount of $ . Other request regarding the property: (describe the request fully) 11. Additional Real Property None OR Awarding solely to Petitioner Respondent all right, title, and interest of husband and wife in the real property located at: Street address___________________________________________________________________ in the City of , County of ___________________________, State of , which has the following legal description: ______________ _______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Petitioner Respondent: 1st Mortgage: Amount currently owed: $ DIV406 State ENG Rev 4/09 and name of lender: www.mncourts.gov/forms Page 22 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 2nd Mortgage: Amount currently owed: $ and name of lender: and subject to the following liens or other agreements: A lien in favor of Petitioner Respondent in the amount of $ . Other request regarding the property: (describe the request fully) 12. Retirement Funds a. Awarding Petitioner’s pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: Petitioner has no retirement funds OR 100% to Petitioner OR Dividing Petitioner’s retirement benefits fairly and equitably between the parties as follows: b. Awarding Respondent’s pension, profit sharing, retirement plan, I.R.A., or 401(k) or other retirement fund as follows: Respondent has no retirement funds OR 100% to Respondent OR Dividing Respondent’s retirement benefits fairly and equitably between the parties as follows: 13. Debts a. Dividing the debts as follows and ordering each party to hold the other harmless from any responsibility for the debts so divided. Include all debts listed at #27 above. DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 23 of 27 American LegalNet, Inc. www.FormsWorkFlow.com Debt Owed To: To Be Paid By: b. Ordering that each party is solely responsible for paying any other debts incurred solely by him or her and ordering each party to hold the other harmless from any responsibility for such separately incurred debts. 14. Name Change Neither party is requesting a name change. OR Changing Petitioner’s name to: First Middle Last First Middle Last Changing Respondent’s name to: 15. Other: 16. Each party shall execute any and all documents necessary to transfer real and personal property as awarded herein without further order of the Court. Should either party fail to execute the necessary documents, a certified copy of the Judgment and Decree shall operate to transfer title as awarded. 17. 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 DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 24 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 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 and Decree in the court file. NOTICE: APPENDIX A SHALL BE INCORPORATED AND MADE A PART OF THE JUDGMENT AND DECREE. Appendix A contains provisions regarding Payments to Public Agency, Minnesota Statutes § 518A.50; Depriving Another of Custodial or Parental Rights--A Felony, Minnesota Statutes § 609.26; Rules of Support, Maintenance, Parenting Time; Parental Rights from Minnesota Statutes § 518.17, subdivision 3; Wage and Income Deduction of Support and Maintenance, Minnesota Statutes § 518A.53; Change of Address or Residence; Cost of Living Increase of Support and Maintenance pursuant to Minnesota Statutes § 518A.75; Judgments for Unpaid Support pursuant to Minnesota Statutes § 548.091; Judgments for Unpaid Maintenance pursuant to Minnesota Statutes §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. 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 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. DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 25 of 27 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MINNESOTA STATE OF MINNESOTA COUNTY OF _______________________)SS COUNTY OF_____________________)SS (County where document is signed) DATED: ____________________________ DATED: __________________________________ ___________________________________ Signature of Petitioner _________________________________________ Signature of Respondent (Do NOT sign unless in presence of Notary Public) (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 Notary Public/Deputy Court Administrator Petitioner: Respondent: 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 _______________________________________ By _______________________________________________ Attorney for Petitioner Attorney for Respondent ORDER FOR JUDGMENT LET JUDGMENT BE ENTERED IMMEDIATELY. The foregoing facts were found by me after due hearing and the Order thereon is recommended. BY THE COURT ________________________ District Court Referee Judge of District Court Dated:_____________________ Dated:_______________________________ JUDGMENT I certify the above Conclusions of Law are the Judgment of the Court. ___________________________________________ Court Administrator DIV406 State ENG Rev 4/09 www.mncourts.gov/forms Page 26 of 27 American LegalNet, Inc. www.FormsWorkFlow.com 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. 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. My spouse may proceed to judgment pursuant to the terms of said stipulation as if by 4. default, and without further notice to me. __________________________ Date DIV406 State ENG Rev 4/09 ___________________________________________ Signature of Respondent www.mncourts.gov/forms Page 27 of 27 American LegalNet, Inc. www.FormsWorkFlow.com