State of Minnesota District Court Judicial District: Court File Number: Assigned Judge: Case Type: County of Dissolution without Children In Re the Marriage of: Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree Name of Petitioner (first, middle, last) 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 DIV407 State ENG Rev 10/10 www.mncourts.gov/forms Day American LegalNet, Inc. www.FormsWorkFlow.com Year Page 1 of 26 F. Respondent did not respond, so Petitioner proceeded by default. (Note: If the parties reached an agreement, use the Stipulated Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree.) Findings of Fact 1. Information about Petitioner Full Name: First Middle Last Address where you live: Street Address Apt. No. _______ City County Mailing address: State Zip Code Same as above address OR Street Address Apt. No. _______ City County State Date of Birth: ________________________ Month Day Zip Code Petitioner is the 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: Street Address Apt. No. _______________________________________________________________________________ City County State Zip Code Respondent's address is unknown to Petitioner. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 26 Respondent’s 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? YES Has Respondent been living in Minnesota for the past six (6) months? NO YES NO UNKNOWN 5. 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? YES Is Respondent an active duty member of the armed forces? UNKNOWN YES NO If YES, has Respondent been stationed in Minnesota for the past (6) months? DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com YES NO NO Page 3 of 26 6. Marriage Cannot be Saved There has been an irretrievable breakdown of my marriage relationship with Respondent and the marriage 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 , and the status or outcome of the case is: Open 9. Closed Unknown 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. Children Petitioner Respondent County in date, and the Court file number is . “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 themselves because of a physical or mental condition? DIV407 State ENG Rev 10/10 YES www.mncourts.gov/forms NO American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 26 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 the 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 submitted with 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 submitted with 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.) DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 26 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 UNKNOWN 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. NO a. Petitioner receives Supplemental Security Income: YES in the amount of $____________ per month. b. Respondent receives Supplemental Security Income: $____________ per month, or 13. NO YES in the amount of UNKNOWN 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) DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 26 ____________________________________________________________________________ Employer’s Street Address ____________________________________________________________________________ City State Zip Code Name of Petitioner’s Employer (If Self-Employed, list name and business address) ____________________________________________________________________________ Employer’s Street Address ____________________________________________________________________________ City 14. State Zip Code Petitioner’s Gross Income 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 Calculate net monthly self employment revenues as follows: (Annual gross revenues minus annual ordinary and necessary business expenses) divided by 12=Net Monthly Revenue. 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 DIV407 State ENG Rev 10/10 $ _______________ per month www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 7 of 26 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? YES Is Respondent Self-Employed? NO YES UNKNOWN NO UNKNOWN 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 16. State Zip Code Respondent’s Gross Income Petitioner has no information about Respondent’s income. OR Petitioner does not have detailed information about Respondent’s income, but has good reason to believe that Respondent’s pay is $____________per week month year, with bonuses, overtime or commissions in the additional amount of $__________________per week month deductions) or year. This is Respondent’s Net Income (after taxes and Gross Income (before taxes and deductions.) OR Petitioner has detailed information about Respondent’s income. (If this is true, fill out the income information below.) DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 8 of 26 The Income questions ask for monthly income. If Respondent is paid weekly, multiply weekly income by 4.33 to get monthly income. If Respondent is paid every two weeks, multiply by 2.17 to get monthly income. If paid twice a month, multiply by 2. Source of Income Amount per month (or zero) before taxes and deductions Self Employment Income $________________per month Calculate net monthly self employment revenues as follows: (Annual gross revenues minus annual ordinary and necessary business expenses) divided by 12=Net Monthly Revenue. 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 $ _______________ per month 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: DIV407 State Petitioner ENG YES Petitioner NO Respondent and this dental insurance Respondent Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 9 of 26 b. Does Respondent have insurance coverage through his/her employment? Medical: YES NO UNKNOWN Dental: YES NO UNKNOWN If YES, this medical insurance covers: and this dental insurance covers: c. Respondent YES NO Does Respondent receive Medical Assistance or Minnesota Care through the State of Minnesota? 18. Petitioner Respondent Does Petitioner receive Medical Assistance or Minnesota Care through the State of Minnesota? d. Petitioner YES NO UNKNOWN Spousal Maintenance Spousal Maintenance is money paid by one spouse to the other for living expenses. Check only one box: Petitioner and Respondent can each pay their own living expenses and do not need spousal maintenance at this time, or in the future. Petitioner or Respondent 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. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 10 of 26 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 UNKNOWN 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 Balance Owed Monthly Title Payment $ $ $ $ $ $ $ $ $ 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 already, to Petitioner’s satisfaction? DIV407 State YES ENG NO Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 11 of 26 If NO, Petitioner 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 UNKNOWN If YES, list Respondent’s non-marital property: ___________________________________________________________________________. 22. Cash & Accounts – Not including Pension and Employer-Funded Retirement Accounts Does Petitioner have money in banks, savings, cash or investments? YES NO Does Respondent have money in banks, savings, cash or investments? YES NO UNKNOWN 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. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 12 of 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. . OR UNKNOWN Business Interest Does Petitioner have an interest in a business? YES NO Does Respondent have an interest in a business? YES NO UNKNOWN If YES, the name of the business is ____________________________, the address is _______________________________________________________________________________ and the value is $________________. How did you arrive at this value? 24. Manufactured Home Does Petitioner own a manufactured home? YES NO Does Respondent own a manufactured home? YES NO UNKNOWN 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 DIV407 State , state of ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 13 of 26 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? YES NO Does Respondent own real property solely in his/her own name or with someone other than Petitioner? YES NO UNKNOWN How many properties are owned by you and your spouse in total? None One Two Three _______ 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 DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 14 of 26 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: 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 DIV407 State ENG Rev 10/10 _________No www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 15 of 26 26. 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 UNKNOWN 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 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 UNKNOWN If YES, and it is a Pension, Profit-Sharing, or other Retirement Plan: a) The name of the plan is: DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 16 of 26 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 UNKNOWN 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 $ $ $ $ $ $ $ $ $ $ www.mncourts.gov/forms $ $ Rev 10/10 $ $ ENG $ $ State $ $ DIV407 $ $ Total Debt $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Page 17 of 26 28. Name Change Does Petitioner want to change his/her name? YES NO If YES, answer (a) through (c): a. Petitioner’s name should be changed to: first middle Is this a former legal name or maiden name? last YES NO If NO, the reason Petitioner wants to change to this name is: b. Petitioner has no intent to defraud or mislead anyone by changing his/her name: True False. c. Has Petitioner 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 Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree. 29. Other Findings ___________________________________________________________________________ BASED UPON THE ABOVE INFORMATION, the Court makes the following: CONCLUSIONS OF LAW 1. The bonds of matrimony between Petitioner and Respondent are dissolved, so they are single and not married. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 18 of 26 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. 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 in the amount of $ Respondent shall pay permanent spousal maintenance to the other party per month starting on (date): . Any past due amounts are still owed. d. Petitioner in the amount of $ Respondent shall pay temporary spousal maintenance to the other party 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. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 19 of 26 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 5. Awarded to: 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): DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 20 of 26 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 $ XX $ 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 DIV407 State ENG Rev 10/10 www.mncourts.gov/forms Petitioner American LegalNet, Inc. www.FormsWorkFlow.com Respondent. Page 21 of 26 10. 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: $ 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: DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 22 of 26 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: $ 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) 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: DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 23 of 26 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. 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 Petitioner is not requesting a name change. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 24 of 26 Changing Petitioner’s name to: First Middle Last 15. Other: 16. Other: 17. 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. 18. Petitioner shall personally serve Respondent with a copy of the Judgment and Decree by having a third party (the server), age 18 or older, hand a copy of the Judgment and Decree to Respondent. The server’s Affidavit of Service, filed with the Court by Petitioner, will be proof of service. 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. DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 25 of 26 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 and Judgment is hereby entered. ___________________________________________ Court Administrator Deputy Dated: DIV407 State ENG Rev 10/10 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 26 of 26