State of Minnesota District Court Judicial District: Court File Number: Assigned Judge: Case Type: County of Dissolution with 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 ________________________. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 1 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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 F. Day Year Check One: Respondent did not respond, so Petitioner proceeded by default. Petitioner and Respondent reached an agreement and signed a Marital Termination Agreement, the terms of which are set forth in this document as Conclusions of Law. Petitioner and Respondent reached an agreement at Court. The Agreement is not in writing. Petitioner prepared the Findings of Fact, Conclusions of Law, Order for Judgment and Judgment and Decree, and included the terms of the parties’ Agreement. Respondent approves of the agreement as noted by his or her signature on the last page of this document. Findings of Fact 1. Information about Petitioner Full Name: _______________________________________________________________________ First Middle Last Address: Street Address Apt. No. _______ City County State Mailing address where Petitioner agrees to receive papers for this case: OR Zip Code Same as above address ________________________________________________________________________ Street Address Apt. No. _______ City County Date of Birth: ________________________ Month Day State Petitioner is the Zip Code husband wife. Year List all of Petitioner’s former or other names or write “None”: First State Last First DIV807 Middle Middle Last ENG Rev 4/09 www.mncourts.gov/forms Page 2 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 2. Information about Respondent Full Name: First Middle Last Address: Street Address Apt. No. City County State Zip Code Respondent's address is unknown. 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 NO Has Respondent been living in Minnesota for the past six (6) months? YES 5. NO UNKNOWN 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? 6. YES NO NO Marriage Cannot be Saved There has been an irretrievable breakdown of the marriage relationship and the marriage between Petitioner and Respondent cannot be saved. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 3 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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 at this time because: 8. Other Proceedings a. Has a separate court case for marriage dissolution, legal separation, custody, paternity or annulment already been started by Petitioner or Respondent in Minnesota or elsewhere? NO YES If YES, the type of court case is: , and it was started in ________________________ County in the State of __________________ and the Court file number is Open , and the status or outcome of the case is: Closed Unknown or b. Has a County started a Support case involving the Petitioner and the Respondent or their children? YES NO If YES, the case was started in ________________________ County in the State of ____________________ and the Court file number is The case is 9. Dismissed or Pending or . an Order for Support was issued. Protection or Harassment Order Is an Order for Protection or a Harassment/Restraining Order in effect regarding Petitioner and Respondent? YES NO If YES: a. The Order protects: Petitioner in Respondent the child(ren) and the Order was filed County in State on date, and the Court file number is . b. Does the Order for Protection include an order to pay child support? 10. YES NO Juvenile Court Case Is a Juvenile Court case (child protection, delinquency or foster care) involving husband's and wife’s joint child(ren) taking place in Minnesota or another state? DIV807 State ENG Rev 4/09 www.mncourts.gov/forms YES NO Page 4 of 37 American LegalNet, Inc. www.FormsWorkFlow.com If YES, the case is in County in the State of __________________ and the Court file number is . The name of the child or children involved in the Juvenile Court case is: . 11. Children Husband and Wife have Together (Joint Children) a. Are there any children born to or adopted by husband and wife together, either before or during the marriage? YES NO If YES, Full Name of Child Date of Birth Age Child Currently Lives With Petitioner Respondent Both parents OR _______________________(write in name) Petitioner OR Both parents Respondent Both parents ________________________(write in name) Petitioner OR Respondent ________________________(write in name) Petitioner OR Both parents ________________________(write in name) Petitioner OR Respondent Respondent Both parents ________________________(write in name) If a child is living with someone other than a parent, write the child's address below: Address: ______________________________________________________________________ Street Address Apt. No. City County State Zip Code b. Has each child born to or adopted by husband and wife together lived in Minnesota for the past six (6) months? YES NO If NO, name the child or children, name the State(s) the child has lived in during the past 6 months, and the dates the child lived in each state: 12. Adult Dependent Children Support can be ordered for a joint child over age 18 who cannot support him/herself because of a physical or mental condition. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 5 of 37 American LegalNet, Inc. www.FormsWorkFlow.com Is there an adult joint child born to or adopted by Husband and Wife who is not able to support himself or herself because of a physical or mental condition? YES NO If YES, the full name, date of birth and age of each adult dependent is: Full Name of Dependent Date of Birth 13. Age Pregnancy a. Petitioner b. Respondent is the wife in this marriage. Is wife pregnant? YES NO UNKNOWN If wife is pregnant answer (i) and (ii): (i) The date the baby is due is OR Month Day UNKNOWN Year (ii) Do Wife and Husband agree that husband is the biological father of the unborn child? YES If NO, 14. NO Wife Husband claims husband is not the biological father of the child. Husband’s Children from Other Relationship (Non-Joint Children) Does Husband have minor child(ren) from another marriage or relationship? YES NO UNKNOWN If YES, the full name, date of birth and age of each child is: Full Name of Child and Age Date of Birth Does Child Live with Husband? YES NO Is Husband Court-Ordered to pay Child Support for this Child? YES NO YES YES NO YES NO YES NO YES NO YES NO YES 15. NO NO YES NO Wife’s Children from Other Relationship (Non-Joint Children) a. Does Wife have minor child(ren) born prior to the marriage from another marriage or relationship? DIV807 State ENG YES Rev 4/09 NO UNKNOWN www.mncourts.gov/forms Page 6 of 37 American LegalNet, Inc. www.FormsWorkFlow.com If YES, the full name, date of birth and age of each child born prior to the marriage is: Full Name of Child and Age Date of Birth Does Child Live with Wife? YES NO Is Wife Court-Ordered to pay Child Support for this Child? YES NO YES NO YES NO YES NO YES NO YES NO YES NO b. Has Wife given birth, since marrying Husband, to a minor child who is not a child of the Husband? YES NO If YES, answer (i) , (ii), (iii) and ( iv): (i) List the full name, date of birth and age of each child born to Wife since marrying Husband, who is not a child of the Husband: Full Name of Child and Age Date of Birth Does Child Live with Wife? YES NO YES (ii) Is Wife Court-Ordered to pay Child Support for this Child? YES NO NO YES NO Is there a Court Order naming someone other than the Husband as the father of the child(ren) listed in (i) above? YES NO The Order is for: _____________________________________________________ Full Name of Child(ren) (iii) Have the Wife and biological Father signed a Minnesota Recognition of Parentage for any of the children listed in (i) above? YES If YES, state the full name of the child: NO and attach a copy of the Recognition of Parentage. If NO, why not? (iv) 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: If NO, why not? DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 7 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 16. Parenting Time It is in the best interests of the children that: Petitioner's parenting time with the joint children be: (check one) unsupervised supervised reserved Respondent's parenting time with the joint children be: (check one) unsupervised supervised reserved If parenting time is unsupervised for both parents, skip to Question 17. For supervised parenting time answer a. and b. For reserved parenting time, answer c. a. Supervision is necessary because unsupervised parenting time is likely to endanger the child's physical or emotional health or impair the child's emotional development. The circumstances supporting this finding are: b. It is in the best interests of the child(ren) that supervision of parenting time be arranged as follows: (State who should supervise parenting time, and if there is a cost involved, who should pay the cost, and any other important details) c. Parenting time should be reserved because: 17. Public Assistance from State of Minnesota If either party is receiving public assistance from the State of Minnesota or applies for it after this proceeding is started, the Petitioner must give notice of this marriage dissolution action to the Support and Collections office for the county paying the assistance. a. Does Petitioner receive public assistance from the State of Minnesota? YES NO If YES, the assistance is from __________________ County. (Check all that apply): MFIP in the amount of $___________per month Tribal TANF in the amount of $__________per month DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 8 of 37 American LegalNet, Inc. www.FormsWorkFlow.com General Assistance in the amount of $___________per month Child Care Assistance MinnesotaCare Medical Assistance b. Does Respondent receive public assistance from the State of Minnesota? YES NO UNKNOWN If YES, the assistance is from __________________ County. (Check all that apply): MFIP in the amount of $___________per month Tribal TANF in the amount of $__________per month General Assistance in the amount of $___________per month Child Care Assistance MinnesotaCare Medical Assistance c. Do the joint children of the parties receive public assistance from the State of Minnesota? YES NO UNKNOWN If YES, the assistance is from __________________ County. (Check all that apply): MFIP Medical Assistance Tribal TANF MinnesotaCare IV-E Foster Care 18. 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. Does Petitioner receive Supplemental Security Income (SSI)? NO YES in the amount of $___________per month. b. Does Respondent receive Supplemental Security Income (SSI)? NO YES in the amount of $___________per month. c. Do any of the joint children of the parties receive Supplemental Security Income (SSI)? NO YES in the amount of $___________per month. What is the name of the child Receiving SSI?____________________________________________________________ 19. School Is Petitioner currently enrolled in school? YES NO If Yes: a. The name of the school is b. The type of school is . High School College Vocational Other c. The type of degree expected is____________________________and the expected graduation date is __________________________. Is Respondent currently enrolled in school? DIV807 State ENG Rev 4/09 YES NO www.mncourts.gov/forms UNKNOWN If Yes: Page 9 of 37 American LegalNet, Inc. www.FormsWorkFlow.com a. The name of the school is b. The type of school is . High School College Vocational Other c. The type of degree expected is____________________________and the expected graduation date is __________________________. 20. Petitioner’s Employment a. Is Petitioner employed? YES NO Is Petitioner Self-Employed? b. Is Petitioner working at least 40 hours per week? YES YES NO NO If Petitioner is unemployed or working less than 40 hours/week, answer these questions: i. Why is Petitioner unemployed or working less than 40 hours/week. ii. What is Petitioner's past work experience (type of jobs, hours, pay, length of time at the job) and what are Petitioner's professional qualifications or licenses? c. Current Employment: (If Petitioner has more than two jobs at this time, use an attachment for the additional jobs.) ____________________________________________________________________________ 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) ____________________________________________________________________________ Employer’s Street Address ____________________________________________________________________________ City DIV807 State State ENG Rev 4/09 www.mncourts.gov/forms Zip Code Page 10 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 1st Job Questions about Current Jobs Is Petitioner paid by the hour or hourly 2nd Job salary hourly salary salaried? What is the average number of hours Petitioner works per week? ________________hours ________________hours How much overtime pay does Petitioner receive per week on $_____________________ $____________________ average? Does Petitioner receive bonuses? Yes If Yes, how much was received in If Yes, how much was received in No bonuses last year? $_____________ bonuses last year? $_____________ How much do you expect to receive How much do you expect to receive this year? $___________ this year? $___________ 21. Petitioner’s Income Source of Income Amount Per Month (or zero) before deductions/taxes Self Employment Income $________________ per month Self Employment income means gross receipts minus costs of goods sold minus ordinary and necessary business expenses. Job with __________________________ $________________per month Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month) Second Job with _____________________ $________________ per month Third Job with ______________________ $________________ per month Commissions from all jobs $________________ per month Divide the total amount you expect this year by 12 to get a monthly average Unemployment benefits $________________ per month Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) $_________________per month Investment and 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 income____________________________ $________________ per month Identify Source Add all of the above. DIV807 State ENG Total monthly income Rev 4/09 $ ________________ per month www.mncourts.gov/forms Page 11 of 37 American LegalNet, Inc. www.FormsWorkFlow.com Enter the amount of child support Petitioner is court-ordered to pay for any nonjoint child(ren) $________________ per month Enter the amount of spousal maintenance Petitioner is court-ordered to pay to a current or former spouse $________________ per month Enter the amount of Social Security or Veteran's Benefits received by a joint child because of Petitioner's retirement, disability, or other eligibility $________________ per month Which parent receives the payment for the child? Petitioner Respondent 22. Living Expenses for the Family a. Petitioner and Respondent and their children are still living together. Current monthly living expenses for the family total $ . OR b. Petitioner and Respondent are living separately. The monthly family living expenses before separation totaled $ . At this time, Petitioner's separate monthly living expenses total $____________, and Respondent's monthly living expenses total $______________or are UNKNOWN. Of the total current monthly living expenses for Petitioner, $_______________ amount is for expenses just for the children that live with Petitioner. Of the total current monthly living expenses for Respondent, $___________is for expenses just for the children that live with Respondent, or 23. this is UNKNOWN. Expenses for Special Needs for the Children a. Is there a child of the parties who has special needs and extraordinary medical expenses? YES NO If Yes, Name of child with special needs: Describe the needs: b. Does Petitioner’s monthly living expense (stated at #22) include the special needs expenses for the child? YES NO c. Does Respondent’s monthly living expense (stated at #22) include the special needs expenses for the child? 24. YES NO Respondent’s Employment a. Is Respondent employed? DIV807 State ENG Rev 4/09 YES NO UNKNOWN www.mncourts.gov/forms Page 12 of 37 American LegalNet, Inc. www.FormsWorkFlow.com b. Is Respondent Self-Employed? YES NO UNKNOWN c. Is Respondent working at least 40 hours per week? YES NO UNKNOWN If Respondent is unemployed or works less than 40 hours/week, answer these questions: i. Explain why Respondent is not working or why Respondent works less than 40 hours/week ii. What is Respondent's past work experience (type of jobs, hours, pay, length of time at the job) and professional qualifications or licenses? d. Current Employment: (If Respondent has more than two jobs at this time, use an attachment for the additional jobs.) ____________________________________________________________________________ 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 st Questions about Jobs nd 1 Job 2 Job Is Respondent paid by the hour or hourly salary salaried? hourly Unknown Unknown What is the average number of hours ________________hours Respondent works per week? salary ________________hours Unknown Unknown How much overtime pay does Respondent receive per week on $_____________________ average? $____________________ Unknown Does Respondent receive bonuses? Yes No Unknown DIV807 State ENG Unknown If Yes, how much did Respondent If Yes, how much did Respondent receive Rev 4/09 in bonuses last year? receive www.mncourts.gov/forms in bonuses last year? Page 13 of 37 American LegalNet, Inc. www.FormsWorkFlow.com $___________ $_________ How much does Respondent expect How much does Respondent expect to receive this year? $___________ 25. to receive this year? $___________ Respondent’s Income Respondent's Sources of Income Amount Per Month (or zero) before deductions/taxes Self Employment Income $___________________ (or zero) Self Employment Income means gross receipts minus costs of goods sold minus ordinary and necessary business expenses. Job with______________________________ $ ___________________ per month Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month) Second job with________________________ $____________________ per month Commissions from all jobs $____________________ per month Divide the total amount expected this year by 12 to get a monthly average Unemployment benefits $____________________ per month Social Security Retirement, Survivors or Disability Income (RSDI) (do not include SSI) $____________________ per month Investment and 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 received by Respondent $____________________ per month Other income____________________________ $____________________ per month Identify Source Add all of the above. Total monthly income $ ____________________ per month Enter the amount of child support Respondent is court-ordered to pay for any nonjoint child(ren) $____________________ per month Enter the amount of spousal maintenance Respondent is court-ordered to pay to a current or former spouse $____________________ per month Enter the amount of Social Security or Veteran's Benefits provided to a joint child because of Respondent's retirement, disability, or other eligibility $_____________________ per month Which parent receives the payment for the child? DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 14 of 37 American LegalNet, Inc. www.FormsWorkFlow.com Petitioner Respondent OR The Court does not have detailed information about Respondent's income, but finds that Respondent's pay is $________________ per week month year, with bonuses, overtime or commissions in the additional amount of $________________ per week month year. This is Respondent's Net Income (after taxes and deductions) or Gross Income (before taxes and deductions.) OR 26. Child Care Costs Are there child care costs for joint children because of work or school? YES NO UNKNOWN If YES, a. How many of the joint children need child care? One Two Three ______________ b. How much does the daycare center(s) or babysitter charge per month? $ c. Who pays the child care costs? Petitioner pays $ per month Respondent pays $ per month The County pays $ per month through a subsidy or child care assistance. If the County pays, who applied for the child care assistance? Petitioner Respondent There is no county assistance 27. Health Care Coverage a. Who receives Minnesota Care or Medical Assistance? Petitioner Respondent Joint Children No one b. Does Petitioner have medical insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to c. i. Where does Petitioner get the medical insurance? through his/her employment buys private medical insurance DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 15 of 37 American LegalNet, Inc. www.FormsWorkFlow.com ii. How much does the medical insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage iii. Who is currently covered by this medical insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Nonjoint children Name the joint children who are covered_____________________________________ c. Does Petitioner have dental insurance? (other than MN Care or Medical Assistance) Yes No. If no, skip to d. i. Where does Petitioner get the dental insurance? through his/her employment buys private dental insurance ii. How much does the dental insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage Or, Dental is included in the medical insurance costs. iii. Who is currently covered by this dental insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Name the joint children who are covered____________________________________ Nonjoint children d. Does Respondent have medical insurance? (other than MN Care or Medical Assistance) Yes No Unknown. If No/ Unknown, skip to e. i. Where does Respondent get the medical insurance? through his/her employment buys private medical insurance ii. How much does the medical insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage iii. Who is currently covered by this medical insurance? Petitioner Respondent All the Joint Children Name the joint children who are covered____________________________________ Some of the Joint Children: Nonjoint children e. Does Respondent have dental insurance? (other than MN Care or Medical Assistance) Yes DIV807 State ENG No Unknown If No/ Unknown skip to f. Rev 4/09 www.mncourts.gov/forms Page 16 of 37 American LegalNet, Inc. www.FormsWorkFlow.com i. Where does Respondent get the dental insurance? through his/her employment buys private dental insurance ii. How much does the dental insurance cost? $____________per month for single coverage $____________per month for single plus spouse (if this is offered) $____________per month for family coverage Or, Dental is included in the medical insurance costs. iii. Who is currently covered by this dental insurance? Petitioner Respondent All the Joint Children Some of the Joint Children: Name the joint children who are covered_____________________________________ Nonjoint children f. If the joint children are without health care coverage, is coverage available for purchase through Petitioner's or Respondent's employer? YES NO The children currently have health coverage g. Other: 28. Spousal Maintenance 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: . DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 17 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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. 29. 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 Does Respondent own a vehicle? NO 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 $ $ $ $ $ $ $ $ $ 30. $ $ $ 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 already in a manner satisfactory to Petitioner and Respondent? YES NO If NO, Petitioner requests the following marital property: ________________________________________________________________________________ DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 18 of 37 American LegalNet, Inc. www.FormsWorkFlow.com ________________________________________________________________________________ If NO, Respondent requests the following marital property: ________________________________________________________________________________ ________________________________________________________________________________ 31. 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 non-marital 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: ___________________________________________________________________________. 32. Cash & Accounts – Not including Pension and Employer-Funded Retirement Accounts Does Petitioner have money in banks, savings, cash or investments? YES Does Respondent have money in banks, savings, cash or investments? YES NO NO UNKNOWN If YES, a. List all accounts owned by one spouse alone or owned by both spouses 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 #36. Financial Type of Account Account # Amount (name on account) Last 4 digits only Institution XX ENG Rev 4/09 $ XX State $ XX DIV807 Belongs to: $ www.mncourts.gov/forms Page 19 of 37 American LegalNet, Inc. www.FormsWorkFlow.com XX $ XX $ XX $ b. List cash not listed at a.: Petitioner has cash in the amount of $ Respondent has cash in the amount of $ 33. . 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 $________________. This value is based on: 34. 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 , 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? DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Rent Own Page 20 of 37 American LegalNet, Inc. www.FormsWorkFlow.com Note: If you own the lot, you must list the land at Paragraph 35. 35. 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? b. Does Petitioner own real property solely in his/her own name or with someone other than Respondent? b. NO NO Does Respondent own real property solely in his/her own name or with someone other than Petitioner? c. YES YES YES NO UNKNOWN How many properties are owned by Petitioner and Respondent in total? None One Two Three _______ If Petitioner or Respondent 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 this Decree, and label each sheet "Attachment to Findings of Fact, Conclusions of Law, Order for Judgment, Judgment and Decree 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. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 21 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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 was this value determined? 7. This property is the homestead: _______Yes 36. _________No Retirement Plans a. 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: b. 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: c. DIV807 Does Respondent have a retirement account? (IRA, 401(k), 403(b) or other) State ENG Rev 4/09 www.mncourts.gov/forms Page 22 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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: d. 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: 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: ___________________________________ 37. Debts Does Petitioner have debt? YES NO Does Respondent have debt? YES NO UNKNOWN If YES, list debts in Petitioner's name, Respondent'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 4/09 $ $ ENG $ $ State $ $ DIV807 $ $ Page 23 of 37 American LegalNet, Inc. www.FormsWorkFlow.com $ $ 38. $ $ $ $ Total Debt $ $ Name Change Does Petitioner want to change his/her name? YES NO If YES, answer (a) through (c) below: a. Petitioner’s name should be changed to First Middle Is this name a former legal name or maiden name? YES NO Last 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 c. False Has Petitioner been convicted of a felony? YES NO If YES, has Petitioner given notice of this request for name change to the proper authority as required by Minn. Stat. Section 259.13? YES Does Respondent want to change his/her name? NO YES NO If YES, answer (d) through (f) below: d. Respondent’s name should be changed to First Middle Is this name a former legal name or maiden name? YES NO Last If NO, the reason Respondent wants to change to this name is: ________________________________________ ____________________________________________________________________________ ________________ e. Respondent has no intent to defraud or mislead anyone by changing his/her name: True f. False Has Respondent been convicted of a felony? YES NO If YES, has Respondent given notice of this request for name change to the proper authority as required by Minn. Stat. Section 259.13? DIV807 State ENG Rev 4/09 YES NO www.mncourts.gov/forms Page 24 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 39. 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. 2. Legal Custody means which parent(s) have a say in the major decisions regarding the child(ren)’s life including education, religious upbringing and medical treatment. Granting legal custody of each minor joint child of the parties as follows: Name of Child Granting Legal Custody: Solely to Petitioner OR Solely to Respondent OR Jointly to both parties. Solely to Petitioner OR Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. 3. Physical custody identifies which parent(s) will handle the routine daily care and control of the child(ren). Granting physical custody of each of the minor joint children of the parties as follows: Name of Child Granting Physical Custody: Solely to Petitioner OR Solely to Respondent OR Jointly to both parties. Solely to Petitioner OR Solely to Respondent OR Jointly to both parties. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 25 of 37 American LegalNet, Inc. www.FormsWorkFlow.com Solely to Petitioner OR Solely to Respondent OR Jointly Solely to Respondent OR Jointly Solely to Respondent OR Jointly to both parties. Solely to Petitioner OR to both parties. Solely to Petitioner OR to both parties. 4. Parenting Time a. Petitioner's parenting time shall be: Unsupervised Supervised Reserved b. Respondent's parenting time shall be: Unsupervised Supervised Reserved c. Parenting Time shall be scheduled as follows: (Clearly explain the time each parent will spend with each child. Include the time (o'clock) when the child will transfer from one parent to the other. If you want the order to say who will pick up and drop off the child, include that under "Other.") Regular schedule: Monday through Friday: Weekends: Summer (if you want a different schedule in summer) Telephone contact with the child(ren): Unlimited or Only at certain times as follows: (describe the days and times when the parent and child(ren) may have telephone contact) Exceptions to the Regular Schedule: DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 26 of 37 American LegalNet, Inc. www.FormsWorkFlow.com You can have a different schedule for holidays, school release days, and birthdays. If you do not want a different schedule, leave it blank. School Release days or breaks during the school year Any school release day schedule will supercede the regular parenting schedule. Birthdays (child's birthday, parent's birthday) Holidays Any holiday or birthday schedule will supercede the regular and school release parenting schedule. Other d. Under the above Schedule: The children are with Petitioner: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time 5. The children are with Respondent: less than 10% of the time 10-45% of the time 45.1-50% of the time more than 50% of the time Basic Support for the Children (Choose a. or b.) a. Petitioner Respondent shall pay to Petitioner Respondent $___________ per month starting on (date):___________________as the basic support obligation for the parties’ minor child(ren). Any past due amounts of child support are still owed. If this amount is more or less than the basic support obligation under Minnesota laws, the facts supporting the deviation from the basic amount are: The monthly amount shall be: DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 27 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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 child support is self-employed, 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 IV-D services or income withholding-only services at the Child Support office in the County where the children live. Until income withholding starts, the person owing support shall pay the other parent directly. OR The monthly amount shall be paid directly by the parent owing the child support to the parent receiving the child support, payable on the ____________________day of each month. b. Child Support shall be reserved because: Either party can ask the court to order the payment of child support in the future by filing a Motion stating that there is a change in circumstances. 6. Medical and Dental Insurance for the Minor Children Ordering Medical insurance as follows: a. Petitioner Respondent shall provide medical insurance for the minor child(ren) child(ren) through his/her employer or union. The other parent must pay a pro rata share of the health coverage costs by paying_________________________ OR pay nothing toward the medical insurance costs because he/she is financially unable to contribute to the costs. OR b. Petitioner Respondent shall provide medical insurance for the minor child(ren) by obtaining and paying for private insurance. The other parent must pay a pro rata share of the health coverage costs by paying OR pay nothing toward the medical insurance costs because he/she is financially unable to contribute to the costs. OR c. DIV807 Petitioner State ENG Respondent shall pay $ Rev 4/09 www.mncourts.gov/forms per month, per child, as Page 28 of 37 American LegalNet, Inc. www.FormsWorkFlow.com reimbursement for Medical Assistance or Minnesota Care, payable by income withholding through the Minnesota Child Support Payment Center, provided Medical Assistance or Minnesota Care is open for the child(ren). OR d. Reserving the issue of medical insurance for the minor children. Ordering Dental Insurance as follows: a. Petitioner Respondent shall provide dental insurance for the minor child(ren) through his/her employer or union. The other parent must pay a pro rata share of the dental coverage costs by paying OR pay nothing toward the dental insurance costs because he/she is financially unable to contribute to the costs. OR b. Petitioner Respondent shall provide dental insurance for the minor child(ren) by obtaining and paying for private insurance. The other parent must pay a pro rata share of the dental coverage costs by paying OR pay nothing toward the dental insurance costs because he/she is financially unable to contribute to the costs. OR c. Reserving the issue of dental insurance. Other: ______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________. 7. Uninsured and Unreimbursed Medical and Dental Expenses for the Children a. Petitioner shall pay _________ % of the uninsured and/or unreimbursed medical and dental costs for the minor child(ren) of the parties, and Respondent shall pay __________ % based on the percentage share of combined PICS (parental income for determining child support.) OR b. Reserving the issue of uninsured and unreimbursed medical and dental costs. "Unreimbursed medical and dental costs" are expenses not covered by insurance, not paid by medical assistance, and not paid by the State of Minnesota. Examples include deductibles, co-pays, and procedures not covered by insurance or assistance. Usually the parent with physical custody of the child will receive and pay the bill for the unreimbursed costs. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 29 of 37 American LegalNet, Inc. www.FormsWorkFlow.com The parent who paid the bill must ask the other parent to pay his/her percentage share. To ask for payment, send to the other parent a) a copy of the bill, b) evidence that you have paid the bill, and c) a letter requesting payment to you in the amount of $_____. This request for payment should be made promptly, and no later than 3 months after the bill is paid. If a request for payment is made after 3 months, there must be exceptional circumstances to support the late request for payment. The person receiving the request for payment shall make the payment within 30 days. If there is a good reason to question the payment, send a letter to the other parent stating what additional information is needed, or why payment is disputed. If neither payment nor a written letter disputing payment is sent within 30 days of receiving the request for payment, then the unpaid bill can be considered back due child support. If the parents are not able to work out payment problems, either parent can bring a motion in Court asking the Court to decide the dispute, or asking the Court to adjust how they divide the bills, based on changes in the incomes of the parents. 8. Medical and Dental Insurance for the Parties a. Each party shall provide for his or her own medical dental insurance. b. ____________________________(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. 9. Child Care Expenses a. Petitioner shall pay $ per month for child care expenses, and Respondent shall pay $ per month for child care expenses; OR b. Reserving the issue of child care expenses. 10. Spousal Maintenance a. Neither party is awarded spousal maintenance. b. Maintenance is reserved because: DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 30 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 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. 11. Vehicles The vehicles are awarded as follows, and the party receiving the vehicle shall pay for any loans or insurance for such vehicle: Year / Make / Model 12. Awarded to: Marital Property The parties’ marital property, household goods, furniture and furnishings are awarded: DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 31 of 37 American LegalNet, Inc. www.FormsWorkFlow.com a. As currently divided OR b. As follows (add pages if necessary): To Petitioner: To Respondent: 13. 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: 14. 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: DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 32 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 15. Business None OR Awarding the parties’ business as follows: _________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 16. 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 17. 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: ______________ _______________________________________________________________________________ _______________________________________________________________________________ with the following mortgages and loans to be paid, after the divorce is final, by Petitioner Respondent: st 1 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 conditions or agreements: A lien in favor of Petitioner Respondent in the amount of $ . Other conditions or agreements about the property: DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 33 of 37 American LegalNet, Inc. www.FormsWorkFlow.com 18. 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: $ and name of lender: 2nd Mortgage: Amount currently owed: $ and name of lender: and subject to the following liens or other conditions or agreements: A lien in favor of Petitioner Respondent in the amount of $ . Other conditions or agreements about the property: 19. Retirement Funds a. Awarding Petitioner’s pension, profit sharing, retirement plan, I.R.A., 401(k) or other retirement fund as follows: 100% to Petitioner OR Other (describe fully): DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 34 of 37 American LegalNet, Inc. www.FormsWorkFlow.com b. Awarding Respondent’s pension, profit sharing, retirement plan, I.R.A., 401(k) or other retirement fund as follows: 100% to Respondent OR Other (describe fully): 20. Debts a. The debts are divided as follows. The person ordered to pay a debt shall hold the other person harmless from any responsibility for the debt. Debt Owed To: To Be Paid By: b. Each party is solely responsible for paying any other debts incurred solely by him or her and each party shall hold the other harmless from any responsibility for such separately incurred debts. 21. 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: 22. Paternity Questions Check only if applicable: The Husband does not have a parent – child relationship with a child or children named: , born to Wife during the marriage, and Husband is not the father. DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 35 of 37 American LegalNet, Inc. www.FormsWorkFlow.com The issue of paternity of the unborn child of Wife is reserved. 23. Other: _______________________________________________ 24. 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 herein. 25. Petitioner shall personally serve Respondent with a copy of the Judgment and Decree by having someone else (the server) hand a copy to Respondent. The server’s Affidavit of Personal Service, filed with the Court by Petitioner, will be proof of service. If Respondent agreed in a Marital Termination Agreement to be served with a copy of the Judgment and Decree by mail, then Petitioner may serve Respondent with a copy of the Judgment and Decree by havingsomeone else mail the copy to Respondent by first class U. S. mail at Respondent’s residence or last known address. The server’s Affidavit of Service by Mail, filed with the Court by Petitioner, will be proof of service. This shall constitute due and proper service of the Decree. 26. 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 Maintenance and Child Support pursuant to Minnesota Statutes § 518A.53; Change of Address or Residence; Cost of Living Increase of Maintenance and Child Support pursuant to Minnesota Statutes § 518A.75; Judgments for Unpaid Maintenance and Child Support 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. ORDER FOR JUDGMENT LET JUDGMENT BE ENTERED IMMEDIATELY. The foregoing facts were found by me after due hearing and the Order thereon is recommended. DIV807 State ENG Rev 4/09 BY THE COURT www.mncourts.gov/forms Page 36 of 37 American LegalNet, Inc. www.FormsWorkFlow.com ________________________ 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 DIV807 State ENG Rev 4/09 www.mncourts.gov/forms Page 37 of 37 American LegalNet, Inc. www.FormsWorkFlow.com