STATE OF INDIANA ) IN THE ) SS: ) CASE NO. COUNTY OF SUPERIOR/CIRCUIT COURT IN RE THE MARRIAGE OF: Petitioner, V. Respondent. DECREE OF DISSOLUTION OF MARRIAGE AND SETTLEMENT AGREEMENT The parties having submitted their Settlement Agreement and the Court having seen and considered the Verified Petition for Dissolution of Marriage and Verified Waiver of Final Hearing submitted by the parties, now approves the following agreement: 1. The parties were married on ________________, and separated on ________________. 2. ____________________________________________________________ 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. Wife is not pregnant and there are no children of the marriage. 4. Neither party is a member of the military. 5. The parties have agreed on the following debt division: The parties already have divided their debts. Petitioner will be solely responsible for and shall hold Respondent harmless from, the following debts: Name of Creditor ______________________________ __________________ ______________________________ __________________ ______________________________ Page 1 of 4 Amount of Debt __________________ Form PS-31152-11 Revised by State Court Administration 10/10 American LegalNet, Inc. www.FormsWorkFlow.com Respondent will be solely responsible for, and shall hold Petitioner harmless from the following debts: Name of Creditor ______________________________ __________________ ______________________________ __________________ ______________________________ 6. 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: ___________________________________________________ Vehicle #1, Make, Model, and Year ___________________________________________________ Vehicle #2, Make, Model, and Year 7. 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: Page 2 of 4 Form PS-31152-11 Revised by State Court Administration 10/10 American LegalNet, Inc. www.FormsWorkFlow.com 8. The marriage has suffered an irretrievable breakdown and should be dissolved. 9. 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. The parties have disclosed all relevant documents and exchanged all information on value of property, pensions, real estate, and other assets and debts. The parties agree that this division of property is/is not an approximate equal division of the assets and debts. The parties agree that if this division is not a nearly equal division, that the deviation from the presumptive equal division should be accepted by the Court because it is the parties’ agreement and neither party has been forced or threatened to accept this agreement. I affirm under the penalties of perjury that the foregoing representations are true. ______________________________ Your Signature STATE OF INDIANA COUNTY OF ____________ ) ) ) SS: Before me, ____________________, a notary public in and for ____________ County, State of Indiana, personally appeared _________________________, and he being first duly sworn upon his/her oath, says that the facts alleged in the foregoing instrument are true. Date ________________ __________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES: _________________________ ______________________________ Spouse’s Signature STATE OF INDIANA COUNTY OF ____________ ) ) ) SS: Before me, __________________, a notary public in and for ______________ County, State of Indiana, personally appeared _________________________, and he being first duly sworn upon his/her oath, says that the facts alleged in the foregoing instrument are true. Date ________________ __________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES: _________________________ Page 3 of 4 Form PS-31152-11 Revised by State Court Administration 10/10 American LegalNet, Inc. www.FormsWorkFlow.com IT IS THEREFORE ORDERED by the Court that the parties’ marriage is hereby dissolved, and the terms of their agreement as set out above shall be incorporated into this Order. ________________________________ Date _________________________________ Judge Distribution: Page 4 of 4 Form PS-31152-11 Revised by State Court Administration 10/10 American LegalNet, Inc. www.FormsWorkFlow.com