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 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 (Select One) 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). Petitioner shall have sole physical custody and the parties shall have joint legal custody of the child(ren) Form #PS-31152-3 Approved by State Court Administration 02/10 Page 10 of 16 American LegalNet, Inc. www.FormsWorkFlow.com Respondent shall have sole physical custody and the parties shall have joint legal custody of the child(ren). Other: ___________________________________________________________ 7. The parties have agreed on the following Parenting Time (Visitation) order: Petitioner shall have reasonable visitation with the minor child(ren) as the parties agree or according to the Indiana Parenting Time guidelines. Respondent shall have reasonable visitation with the minor child(ren) as the parties agree or according to the Indiana Parenting Time guidelines. Other: ___________________________________________________________ 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 _________________. ____________________________________________________________ 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 medical expenses for the minor child(ren). 9. The parties have agreed on the following provisions for health insurance maintenance: ____________________________________________________________ shall maintain medical, dental, and optical insurance as available through employment on the minor child(ren): 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 _______ year thereafter; (Select) Respondent shall be entitled to claim the minor child(ren) in the year ________, and every _______ year thereafter. (Select) Other: ___________________________________________________________ Form #PS-31152-3 Approved by State Court Administration 02/10 Page 11 of 16 American LegalNet, Inc. www.FormsWorkFlow.com 11. 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 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 Form #PS-31152-3 Approved by State Court Administration 02/10 Page 12 of 16 American LegalNet, Inc. www.FormsWorkFlow.com 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 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. 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 Form #PS-31152-3 Approved by State Court Administration 02/10 Page 13 of 16 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF INDIANA ) ) COUNTY OF ____________) SS: Before me, ______________________________, a notary public in and for ________________ County, State of Indiana, personally appeared ______________________________, and he/she 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: _________________________ ______________________________ Your 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/she 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: _________________________ 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: Form #PS-31152-3 Approved by State Court Administration 02/10 Page 14 of 16 American LegalNet, Inc. www.FormsWorkFlow.com