IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of the Marriage of: ________________________________, Co-Petitioner, and ________________________________, Co-Petitioner. STATE OF OREGON County of ) ) ) ) ) ) ) ) ) Case No. CO-PETITIONER’S AFFIDAVIT SUPPORTING STIPULATED JUDGMENT OF DISSOLUTION [With Children] ) ) ss. ) We, and We are co-petitioners in this proceeding. The parties were married on (date): County of , State of , being first duly sworn, say: , in the . □ Irreconcilable differences between the spouses have caused the irremediable breakdown of the marriage. Marriage Only: □ I certify that one or both of the parties to this case currently live in the county in which this petition is being filed. Domestic Partnership Only □ I certify that one or both of the parties to this case currently live in the county in which this petition is being filed, or □ neither party currently resides in Oregon but I certify that this petition is filed in the county where □ Petitioner or □ Respondent last resided. □ No domestic relations suits involving this marriage/domestic partnership of Petitioner and Respondent are pending in any other court. child/ren of the marriage. □ Co-Petitioner, (write name) is pregnant with spouse/partner’s child. □ Co-Petitioner was cohabiting with his/her spouse/domestic partner when the child was conceived. The expected date of the child’s birth is . □ There are □ Neither party is now pregnant. /// /// /// /// /// /// /// AFFIDAVIT SUPPORTING STIPULATED JUDGMENT OF DISSOLUTION [With Children]-PAGE 1 OF 4 9A-Co-Petitioners: AffJudgment9A-Ver05.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com □ Child/ren named were born to in the year , during this □ Co-Petitioner, (write name) marriage/domestic partnership. The spouse/partner is not the parent of the child/ren. □ Co-Petitioner, (write name) was not cohabiting with his/her spouse/domestic partner when the child was conceived. is pregnant at this time and his/her □ Co-Petitioner, (write name) spouse/domestic partner is not the parent of this/these child/ren. □ Co-Petitioner, (write name) was not cohabiting with his/her spouse/domestic partner when this/these child/ren was/were conceived. The expected date of the child/ren’s birth is . This case is now ready for a hearing on the merits. We make this affidavit in support of a General Judgment without a hearing. The allegations in our petition are true and it is just and reasonable that the relief requested be granted in the proposed judgment. □ Child custody or child support is involved in this case and at the time of filing: □ The child/ren had continuously resided in Oregon for six months before this case was filed. □ List any other basis for child custody jurisdiction The current residence of the minor child/ren is/are: Name of Child Resides With (Name, Address or Contact Address) For How Long □ Additional page attached, labeled “Information About Child/ren, Continued.” □ Parenting time should not be ordered because our child/ren’s health or safety would be endangered because: □ I have good reason for the court to allow me to move more than 60 miles further distant from the other parent without giving written advance notice to the other parent. My good cause is: □ Child support or spousal support is involved: □ Co-Petitioner’s, (write name) average gross monthly income is approximately $ . □ Co-Petitioner’s, (write name) .Work or school related daycare is average gross monthly income is approximately $ $ /month and is paid by □ Co-Petitioner, (write name) Health insurance for our child/ren costs $ /month out of pocket and is paid by □ Co-Petitioner, (write name) . /// AFFIDAVIT SUPPORTING STIPULATED JUDGMENT OF DISSOLUTION [With Children]-PAGE 2 OF 5 9A-Co-Petitioners: AffJudgment9A-Ver05.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com The child support amount we have requested □ does not deviate from the amount presumed correct per month under Oregon Administrative Rules, or □ does deviate from the presumed amount of $ because: does □ Child support is involved and □ Co-Petitioner, (write name) not live in Oregon. (If you checked the box above, check any of the following boxes that are true) □ Co-Petitioner lived in Oregon with the child. □ Co-Petitioner lived in Oregon and paid expenses for the birth or support of the child. □ The child was possibly conceived in Oregon. □ The child lives in Oregon because of the wishes of (write name) □ Co-Petitioners both lived in Oregon at the same time (either together or separately) during the marriage for a period of six months, beginning (list dates) and ending on and less than one year has passed since one Co-Petitioner moved to a new residence out of state. □ Other basis for jurisdiction: □ A child support order currently exists and I requested that this court issue a new order because the existing order was issued by an Oregon court or agency, one of the parents or the child/ren receiving support under the order still resides in Oregon, and circumstances have changed since the first order was entered. The changed circumstances are (explain what has changed since the last order): has/have appropriate □ Co-Petitioner/s, (write nam/se) private health care coverage available for the parties’child/ren either through an employer, union, or other source, or through a domestic partner, spouse or other family member residing with them (describe type of coverage): We request that □ Co-Petitioner, (write name) be ordered to maintain this coverage throughout the period of the support obligation for the benefit of the parties’ child/ren. □ Both Co-Petitioners have appropriate private health care coverage available for the parties’ child/ren. We select the following health care coverage to be maintained throughout the period of the support obligation: □ Both Co-Petitioner’s (describe type/s of coverage): □ Co-Petitioner’s, (write name) □ Neither Co-Petitioner has appropriate private health care coverage available for the parties’ child/ren and, □ Co-Petitioner, (write name) □ Both Co-Petitioners should be ordered to apply for and enroll the child/ren in public health care coverage. □ Co-Petitioner, (write name) has already applied to enroll the child/ren in public health care coverage. This coverage should be maintained if the child/ren are accepted for enrollment. □ The child/ren are currently enrolled in public health care coverage. This coverage should be maintained. □ Both Co-Petitioners should be ordered to provide appropriate private health care coverage when such coverage becomes available to them through any source. AFFIDAVIT SUPPORTING STIPULATED JUDGMENT OF DISSOLUTION [With Children]-PAGE 3 OF 5 9A-Co-Petitioners: AffJudgment9A-Ver05.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com □ Cash medical support should be ordered because: □ Neither party has appropriate private health care coverage available for the child/ren. □ The party receiving cash child support is also the party providing private health care coverage. The child support worksheet submitted with our judgment shows that cash medical support per month. should be $ □ Co-Petitioner medical support in the amount of $ should pay, in addition to cash child support, cash per month. □ Cash medical support should not be ordered because: □ Co-Petitioner □ Co-Petitioner has income that is no more than full-time Oregon minimum wage or is/are eligible for Oregon public assistance. □ The parties should share the child/ren’s uninsured medical expenses as described below. □ Other reasons: □ Co-Petitioner, (write name) should pay % □ and □ Co-Petitioner, (write name) should pay % of the uninsured HEALTH, ACCIDENT, DENTAL, ORTHODONTIC, AND OPTICAL HEALTH costs incurred by the child/ren. This obligation should be □ in addition to □ instead of any cash medical support. □ The request for spousal support is supported by the following facts: □ We request that personal information, such as telephone numbers and addresses, not be disclosed in the court’s judgment as otherwise required by ORS 25.020 and ORS 107.085 because a party’s health, safety or liberty, or that of our child/ren would unreasonably be put at risk by such disclosure. State supporting facts: Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: □ We selected this document for ourselves, and we completed it without paid assistance. □ We paid or will pay money to for assistance in preparing this form. Dated: , 20 . Co - Petitioner’s Signature Address or Contact Address Print Name City, State, Zip Telephone or Contact Telephone AFFIDAVIT SUPPORTING STIPULATED JUDGMENT OF DISSOLUTION [With Children]-PAGE 4 OF 5 9A-Co-Petitioners: AffJudgment9A-Ver05.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com SIGNED AND SWORN to before me this day of , 20 , by Notary Public for My Commission Expires: Co - Petitioner’s Signature Address or Contact Address /Court Clerk Print Name City, State, Zip Telephone or Contact Telephone SIGNED AND SWORN to before me this day of , 20 , by Notary Public for My Commission Expires: /Court Clerk I certify that this is a true copy: , Petitioner Signature AFFIDAVIT SUPPORTING STIPULATED JUDGMENT OF DISSOLUTION [With Children]-PAGE 5 OF 5 9A-Co-Petitioners: AffJudgment9A-Ver05.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com