STATE OF INDIANA COUNTY OF (Select One) ) IN THE (Select One) ) SS: ) CASE NO. SUPERIOR/CIRCUIT COURT IN RE THE MARRIAGE OF: Petitioner, V. Respondent. DECREE OF DISSOLUTION OF MARRIAGE The Court having reviewed the Verified Petition for Dissolution of Marriage and having held a final hearing in this matter, now finds the following: 1. The parties were married on __________________, and separated on __________________. 2. (Select One) ______________________________ has been a continuous resident of ___________________ County for the last three months, and the State of Indiana for the last six months prior to the filing of the Verified Petition for Dissolution of Marriage. 3. ______________________________ is not pregnant. 4. Neither party is a member of the military. 5. There were children born of this marriage; namely; Name ______________________________ _________________ ______________________________ _________________ ______________________________ _________________ ______________________________ 6. Date of birth _________________ The parties agree and state that it is in the best interest of the child(ren) that: Petitioner shall have sole physical and legal custody of the child(ren). Respondent shall have sole physical and legal custody of the child(ren). Form #PS-31152-2 Approved by State Court Administration 04/09 Page 13 of 19 American LegalNet, Inc. www.FormsWorkFlow.com Petitioner shall have sole physical custody and the parties shall have joint legal custody of the child(ren) Respondent shall have sole physical custody and the parties shall have joint legal custody of the child(ren). Other: (please describe in detail) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 7. Parenting Time (Visitation) with the minor child(ren) shall be as follows: Petitioner shall have reasonable parenting time (visitation) with the minor child(ren) as the parties agree or according to the Indiana Parenting Time (visitation) guidelines. Respondent shall have reasonable parenting time (visitation) with the minor child(ren) as the parties agree or according to the Indiana Parenting Time (visitation) guidelines. Other: We have agreed to a different parenting time (visitation) that does NOT follow the Indiana Parenting Time (Visitation) Guidelines. (please describe in detail) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 8. ______________________________ will pay child support in the amount of $_______________ per week, as shown by the attached child support worksheet, through the County Clerk’s office, or by income withholding order if available from the employer, beginning on the first Friday following the date of the decree. Said date is _________________. The custodial parent, ______________________________, will be responsible for the first $__________________ of uninsured medical expenses for the minor child(ren). Thereafter, Father shall be responsible for _______% of uninsured medical expenses, and Mother shall be responsible for _______% of uninsured Form #PS-31152-2 Approved by State Court Administration 04/09 Page 14 of 19 American LegalNet, Inc. www.FormsWorkFlow.com medical expenses for the minor child(ren). ______________________________ will be responsible to pay the Administrative Fee that the Clerk charges annually. 9. The parties have agreed on the following provisions for health insurance maintenance: ______________________________ shall maintain medical, dental, and optical insurance as available through employment for the minor children: _________________________________________________________________________ 10. The parties have agreed on the following arrangement for claiming the tax credits, exemptions, and deductions for the minor child(ren): Petitioner shall be entitled to claim the minor child(ren) for federal, state, and local income tax purposes on an annual basis; Respondent shall sign all necessary documents that will entitle Petitioner to do so. Respondent shall be entitled to claim the minor child(ren) for federal, state, and local income tax purposes on an annual basis; Petitioner shall sign all necessary documents that will entitle Respondent to do so. Petitioner and Respondent shall each be entitled to claim the minor child(ren) for federal, state, and local income tax purposes in alternating years; Petitioner shall be entitled to claim the minor child(ren) in the year ________, and every even/odd year thereafter; Respondent shall be entitled to claim the minor child(ren) in the year ________, and every even/odd year thereafter. 11. The parties have agreed on the following debt division: The parties already have divided their debts. Form #PS-31152-2 Approved by State Court Administration 04/09 Page 15 of 19 American LegalNet, Inc. www.FormsWorkFlow.com Petitioner will be solely responsible for and shall hold Respondent harmless from, the following debts: Name of Creditor Amount of Debt ______________________________ $__________________ ______________________________ $__________________ ______________________________ $__________________ Respondent will be solely responsible for, and shall hold Petitioner harmless from the following debts: Name of Creditor ______________________________ $__________________ ______________________________ $__________________ ______________________________ 12. Amount of Debt $__________________ The parties have agreed on the following vehicle division: There are no vehicles to divide. Petitioner will have sole possession of the following vehicles, and Respondent shall execute all documents necessary to transfer title of said vehicles within thirty (30) days of the date of this Order: _______________________________________________ Vehicle #1, Make, Model, and Year _______________________________________________ Vehicle #2, Make, Model, and Year Respondent will have sole possession of the following vehicles, and Petitioner shall execute all documents necessary to transfer title of said vehicles within thirty (30) days of the date of this Order: Form #PS-31152-2 Approved by State Court Administration 04/09 Page 16 of 19 American LegalNet, Inc. www.FormsWorkFlow.com _______________________________________________ Vehicle #1, Make, Model, and Year _______________________________________________ Vehicle #2, Make, Model, and Year 13. The parties have agreed on the following property division: The parties already have divided all items of property. Petitioner will have sole possession of the following items of property: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Respondent will have sole possession of the following items of property: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 14. The marriage has suffered an irretrievable breakdown and should be dissolved. 15. Change of names: Wife would like her maiden name or previous married name of _________________ restored to her. Wife does not want to change her name. IT IS THEREFORE ORDERED by the Court that the parties’ marriage is hereby dissolved. ________________________________ Date _________________________________ Judge Distribution: Form #PS-31152-2 Approved by State Court Administration 04/09 Page 17 of 19 American LegalNet, Inc. www.FormsWorkFlow.com