IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter □ of the Marriage of: ) ) , ) Petitioner, ) ) and ) ) , ) Respondent ) and ) ) ) □ , ) Child who is at least 18 and under 21 years ) of age, unmarried and unemancipated. ) (ORS 107.108) ) Case No. GENERAL JUDGMENT OF SEPARATION 1. This matter came before the Court: □ On the motion and affidavit of Petitioner, the default of Respondent having been found. □ On the motion of Petitioner, the default of Respondent having been found, and Respondent being represented by a guardian ad litem or another person described in Rule 27. □ On the motion and affidavit of Petitioner, Respondent having filed a Waiver of Further Appearance. □ On the stipulations of the parties, as shown by the signatures below. □ At a hearing held , at which the following persons were present: (date) □ Petitioner □ Petitioner’s attorney □ Respondent □ Respondent’s attorney 2. Findings. The Court considered the: □ Affidavit □ Affidavit and stipulations □ Evidence presented and found that: A. Irreconcilable differences between the parties have caused a temporary or unlimited breakdown of their marriage/domestic partnership. □ The parties have entered into an agreement (the terms of this judgment) suspending for a period of not less than one year their obligation to live together as husband and wife/domestic partners, as evidenced by the parties’ signatures on pages 12 and 13 of this judgment. □ Irreconcilable differences exist between the parties and the continuation of the marriage/domestic partnership preserves or protects their legal, financial, social or religious interests. B. □ Spouses Only: □ Petitioner □ Respondent has/have been a resident of and domiciled in the state of Oregon continuously for six months immediately prior to the filing of the Petition for Dissolution of Marriage. GENERAL JUDGMENT OF SEPARATION - PAGE 1 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com □ Domestic Partnership Only: One or both of the parties to this case currently live in the county where this petition has been filed, or □ neither party currently resides in Oregon but the petition has been filed in the county where □ Petitioner or □ Respondent last resided. C. Children of the Marriage/Domestic Partnership. The following children were born to/ adopted by the parties before or during this marriage/domestic partnership (list name(s), date of birth(s) and age(s)): Name Date of Birth Age □ Petitioner □ Respondent is not the father, or paternity has not been established, of the children (list names): born during the marriage/domestic partnership on the following date(s): □ Neither party is now pregnant. □ Petitioner □ Respondent is now pregnant. □ Petitioner □ Respondent is not the parent of the child/ren due (date). D. Child Custody Jurisdiction. (Check appropriate boxes) I. □ Oregon has jurisdiction under the Uniform Child Custody Jurisdiction and Enforcement Act to hear the □ custody □ parenting time issue because: □ Oregon is the child/ren’s home state (i.e., the child/ren have lived here continuously for the six month period immediately before this case was filed). □ Other reason: II. E. □ Oregon does not have jurisdiction under the Uniform Child Custody Jurisdiction Act because: Child/ren Who Are At Least 18 and Under 21 Years of Age. (child/ren’s name) is at least 18 and under 21 years of age, is unmarried and unemancipated and has: □ Waived further appearance in these proceedings. □ Signed and stipulated to the terms of judgment evidenced by the signature below. □ Fully participated in the proceedings and the judgment effectively binds him/her to the terms. NOW, THEREFORE, IT IS HEREBY ORDERED: The terms of this judgment are effective immediately. The parties are hereby legally separated as of the date this Judgment is signed, to continue for the period of time specified in Section 17 below. /// /// GENERAL JUDGMENT OF SEPARATION - PAGE 2 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com 3. Parenting Plan. Custody of the child/ren is awarded as follows: □ Petitioner is awarded sole custody of the following child/ren: □ Respondent is awarded sole custody of the following child/ren:. □ The parties have agreed to joint custody of the following child/ren: as described in the attached parenting plan, labeled “Exhibit 1”. □ Petitioner □ Respondent shall have parenting time with the child/ren in accordance with ☐ the attached local court rule, or □ the attached parenting plan, labeled “Exhibit 1.” □ Petitioner □ Respondent shall have reasonable parenting time with the child/ren upon giving reasonable notice to the other parent. Minimum parenting time, in case of disagreement, shall be: □ Additional page(s) attached, labeled “Exhibit 1 .” □ Petitioner □ Respondent shall not have parenting time because this would endanger the health and safety of the child/ren. □ Parenting time shall be supervised by . □ Any cost of the supervision shall be paid by □ Petitioner □ Respondent □ Other: □ Petitioner and Respondent shall each provide contact addresses and contact telephone numbers to the other and notify each other of any emergency circumstances or substantial changes in the child/ren’s health. □ Neither parent shall move to a residence more than 60 miles further distant from the other parent without giving the other parent reasonable notice of the change of residence and providing a copy of such notice to the court, or □ the requirement of ORS 107.159 regarding notice of move is suspended for good cause found. 4. Child Support, including Cash Medical Support. Check either A or B below: (A) □ No child support shall be ordered at this time because: □ An order for child support in the amount of $ monthly, □ including health care coverage, has already been ordered and docketed with the County Circuit Court, case number . □ Other reason: (B) □ Child support shall be paid by □ Petitioner to Respondent (or) □ Respondent to Petitioner beginning on the □ first or □ of the month following the date of the judgment and continuing on the same day of each month thereafter. The support for each child shall continue until the child reaches eighteen (18) years of age, or is otherwise emancipated, unless the child is a student attending school as defined by Oregon law, in which case support shall continue until the child reaches 21 years of age. Until further order, the total payment per month shall be $ for children. /// /// GENERAL JUDGMENT OF SEPARATION - PAGE 3 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com Cash Medical Support: Of the amount ordered above in paragraph 2B, $ is cash medical. The cash medical support amount ordered is in addition to any percentage of uninsured costs either of the parties is ordered to pay below in paragraph 6(C). (Check if applicable) □ Neither Petitioner or Respondent have appropriate private or public health care coverage available for the parties’ child/ren (see 4(3) below). Cash medical support □ is □ is not ordered and the court’s findings in this regard are as follows: □ Petitioner □ Respondent and/or □ Child/ren are eligible for public medical assistance and cannot be ordered to pay cash medical support. (Check if applicable) □ This order shall modify and replace the following existing order: (List court/agency and case no.) because the court finds that 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 this order was entered. 5 Child Support Calculation (Check any that apply). □ The child support worksheet on which the support amount was calculated is labeled “Exhibit "and attached to and incorporated in this judgment. □ The support award does not deviate from the amount presumed correct under the guidelines set outin the Oregon Administrative Rules. □ The support amount presumed correct under the guidelines set out in Oregon Administrative Rules is $ . The support award deviates from this amount because this Court finds that application of the formula would be unjust or inappropriate in this case because of (check one or more that apply): □ Recurring medical expenses of □ Other 6. Health Care Coverage. (DO NOT FILL THIS SECTION OUT if the boxes in Paragraph 4(A) above have been checked stating that there is an existing child support order that includes health care coverage currently in effect.) A.) PRIVATE INSURANCE IS AVAILABLE □ Petitioner □ Respondent shall name the child/ren as beneficiaries of the following appropriate private health care coverage for the duration of the support obligation (describe type/s of coverage): B.) NO PRIVATE INSURANCE IS AVAILABLE NOW Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties’ child/ren. 1.) □ Petitioner □ Respondent is ordered to apply to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 2.) □ Petitioner □ Respondent has already applied to enroll the child/ren in public health care coverage. If the child/ren is/are accepted for enrollment, this coverage shall be maintained. 3.) □ The child/ren are currently enrolled in public health care coverage. This coverage shall be maintained. 4.) □ Petitioner, □ Respondent □ Both Petitioner and Respondent are ordered to provide GENERAL JUDGMENT OF SEPARATION - PAGE 4 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com appropriate private health care coverage when such coverage becomes available to them through any source. C.) RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES □ Petitioner should pay % and Respondent should pay % of the uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is in addition to any cash medical support ordered above in paragraph 4 as part of the child support award. NOTICE ABOUT PERIODIC REVIEWS If you are receiving child support services through the Department of Justice pursuant to option (a) above, either parent may request that the Department of Justice/Division of Child Support review the amount of support ordered after three years from the date the order took effect or at any time upon the occurrence of a substantial change of circumstances. 7. Payment of Child Support. Pursuant to ORS 25.378(1), an income withholding order shall be issued to enforce the child support obligation unless an exception is indicated below. □ Exceptions to withholding. Income withholding is not ordered at this time because there is no support arrearage, the paying parent has not previously been granted an exemption from withholding, and: □ The parents, and the State, if support rights are assigned, have agreed in writing to an alternative arrangement; or □ Good cause not to require withholding is found because there is proof of timely payment of previously-ordered support and income withholding would not be in the best interests of the child. All payments of child support shall be made (check either (a) or (b) below): (a) □ To the Oregon Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309 or □ by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). (b) □ Pursuant to the above exception, directly to □ Petitioner’s □ Respondent’s checking or savings account. A receipt of deposit shall be kept by the parent paying support as proof of payment. A canceled check is also prima facie evidence that payment has been made. The person receiving support shall provide the paying parent with current deposit slips and/or bank name, account name and account number. NOTICE OF INCOME WITHHOLDING This support order is enforceable by income withholding under ORS 25.378 to 25.390, 25.414 to 25.372 and 25.375. Withholding shall occur immediately, whenever there is an arrearage at least equal to the support payment for one month, whenever the obligated parent requests such withholding, or whenever the obligee requests withholding for good cause. The District Attorney or, as appropriate, the Division of Child Support of the Department of Justice, will assist in securing such withholding. Exceptions may apply in some circumstances. 8. Dependents for Tax Purposes. □ Petitioner □ Respondent shall be entitled to claim the following child/ren as dependent(s) for tax purposes beginning the year this judgment is entered (list names): , OR GENERAL JUDGMENT OF SEPARATION - PAGE 5 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com □ Other (specify): 9. The support obligations ordered in paragraphs 2 through 6 above shall continue until the child reaches 18years of age or is otherwise emancipated, or until the child reaches age 21, so long as the child is a student attending school, as defined by Oregon law. 10. Life Insurance Coverage for Child/ren. □ Petitioner □ Respondent shall obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation if he/she is insurable. The coverage shall be in the amount of $ . NOTICE ABOUT PARENTING TIME AND CHILD SUPPORT The terms of child support and parenting time (visitation) are designed for the child’s benefit and not the parents’ benefit. You must pay support even if you are not receiving parenting time. You must comply with parenting time and visitation orders even if you are not receiving child support. Violation of child support orders and visitation or parenting time orders is punishable by fine, imprisonment or other penalties. Publicly funded help is available to establish, enforce, and modify child support orders. Paternity establishment services are also available. Contact your local district attorney, the domestic relations court clerk, or the Department of Justice at 1-800-850-0228 or 503-378-5567 for information. Publicly funded help may be available to establish, enforce, and modify parenting time or visitation orders. Forms are available to enforce parenting time or visitation orders. Contact the domestic relations, civil court clerk or courthouse facilitator for information. 11. Spousal Support and Life Insurance. □ No spousal support or spousal life insurance is ordered in this case. □ The terms indicated on the inserted Supplement to Judgment shall be in effect. 12. Real Property Distribution. □ Neither Petitioner nor Respondent has any interest in any real property located in this or in any other state. □ Petitioner □ Respondent has/have an interest in real property located at the address of □ This property shall be distributed as follows: □ Additional page labeled “Paragraph 12 - Real Property Distribution continued” attached. □ The legal description of the property is attached as “Exhibit ” and incorporated into this Judgment. □ Petitioner □ Respondent shall be responsible for the preparation, signing and recording of a deed, transferring the real property as required by this judgment. □ Distribution of this property is not within the jurisdiction of this court. GENERAL JUDGMENT OF SEPARATION - PAGE 6 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com 13. Personal Property Distribution (including motor vehicles). □ The Petitioner and Respondent have divided between them all personal effects, household goods and other personal property they own separately or together, and each shall be awarded those items now in their possession. □ The Petitioner is awarded the following personal property: □ Additional page labeled “Paragraph 13 - Petitioner’s Personal Property Distribution continued” attached. □ The Petitioner is awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred compensation plan, and/or stock option plan held by Petitioner’s current or past employer, free of any interest in the Respondent. □ The Respondent is awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred compensation plan, and/or stock option plan held by Respondent’s current or past employer, free of any interest in the Petitioner. □ The Respondent is awarded the following personal property: □ Additional page labeled “Paragraph 13 - Respondent’s Personal Property Distribution continued” attached. 14. Distribution of Debts. □ The debts shall be paid as follows: Name of Creditor (who money is owed to) What debt is for Amount Who shall pay (Petitioner or Respondent) □ Additional page attached, labeled “Paragraph 14 continued”. Each party shall be responsible for the payment of all debts incurred by him or her individually since the date of the separation; all debts which are distributed to him or her by the court; and all debts which are secured by property distributed to that party. Also, if any creditor asks the spouse/domestic partner not responsible for a debt to pay all or a portion of it, and he or she does so, the spouse/domestic partner responsible for that debt shall reimburse the other spouse/domestic partner for any monies he/she paid to the creditor after the date this judgment was entered. The date of separation (when you began living apart) was: /// /// /// /// GENERAL JUDGMENT OF SEPARATION - PAGE 7 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com 15. Transfer of Property and Debts. Within thirty (30) days of the date of this judgment, each party shall execute, acknowledge and deliver whatever documents are necessary to accomplish the distribution of debts and property ordered by the court. The judgment shall operate to convey title to the party awarded the property if the other party fails to comply with this requirement. 16. Former Name. □ Petitioner’s □ Respondent’s former name of is restored. 17. Duration. The length of the separation shall be □ unlimited □ for a period of (length of time) 18. Additional Provisions: □ Additional page attached labeled “Paragraph 16 - Additional Provisions continued”. 19. Court Costs and Fees. A. Deferred Costs and Fees Any court costs and service fees (if service was completed by the Sheriff) that were deferred (required to be paid at a later date) by the court shall be paid by: □ Petitioner □ Respondent. □ Both parties equally □ Other: . B. Costs and Fees Paid by the Parties □ Each party shall be responsible for paying his/her own court costs and service fees for this case. □ To be paid by both parties equally □ Petitioner □ Respondent shall reimburse the other spouse for his/her court costs and service fees for this case. Other: . Judgment shall be entered according to the cost and fee allocation listed above. 20. Information Required by ORS 25.020 and ORS 107.085. □ Based on a finding that the health, safety, or liberty of □ Petitioner □ Respondent or a child, , would unreasonably be put at risk by disclosure of the following information, □ Petitioner □ Respondent has been allowed not to disclose this information. □ Otherwise: Petitioner Respondent Full Name Former Legal Name(s) Age Address or Contact Address Telephone Number GENERAL JUDGMENT OF SEPARATION - PAGE 8 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com Petitioner Social Security Number Do not list. Provided by UTCR 2.100 Affidavit Respondent Do not list. Provided by UTCR 2.100 Affidavit Drivers License Number Employer Name Employer Address Employer Telephone □ Additional page labeled “Paragraph 20 continued” attached. Both parties shall inform the Court and the Department of Justice (P.O. Box 14506, Salem, Oregon 97309) in writing of any change in the above information required by ORS 25.020 within ten (10) days of such change, unless a finding of unreasonable risk has been made in this case. If the court has ordered that a party be allowed not to disclose information by means of this Judgment in Paragraph 20 above, the Department of Justice or the District Attorney shall not disclose the information in the preceding section to the other parent. Date of marriage/domestic partnership: Place of marriage/domestic partnership: 21. . . Money Award. Child Support Obligation □ included □ not included. Spousal Support □ included □ not included. Additional information required by ORS 18.042 PETITIONER RESPONDENT Full Name Address or Contact Address Attorney’s Name, Telephone Number and Address (if applicable) Date of Birth Driver’s License Number and State of Issuance /// /// /// /// /// /// /// GENERAL JUDGMENT OF SEPARATION - PAGE 9 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com The following information is to be provided by any party entitled to receive a money award (a “judgment creditor”) as listed in this Judgment. Others Entitled to Portions of Judgment Payable to PETITIONER The following person(s) or public bod(ies) are known by Petitioner to be entitled to a portion of a payment made on the judgment (other than Petitioner’s attorney): □ None or □ Others Entitled to Portions of Judgment Payable to RESPONDENT The following person(s) or public bod(ies) are known by Respondent to be entitled to a portion of a payment made on the judgment (other than the Respondent’s attorney): □ None or □ Type of Judgment Child Support Award Amount of Judgment WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent Spousal Support Award WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent $ □ Other: the judgment □ per month or □ Other: , starting on the □ first day or of the month following the date of □ Of this Child Support Award, $ ________________ constitutes “cash medical support” 3. $ per month or Other: , starting on the first day or □ Other: of the month following the date of the judgment, lasting until (date), or the death of either party, whichever comes first; or 4. A lump sum payment of $ by (date): to be paid SPOUSAL SUPPORT PAYMENTS ARE TAXABLE TO THE OBLIGEE SPOUSE AND DEDUCTIBLE TO THE OBLIGOR SPOUSE. ALL PAYMENTS TERMINATE UPON THE DEATH OF EITHER PARTY. /// /// /// /// /// /// GENERAL JUDGMENT OF SEPARATION - PAGE 10 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com Property Division (if applicable) WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent □Prejudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) Postjudgment Interest (Note: ORS 21.607(1) disallows interest on fees that have been deferred.) Accrued Arrears (if any, on judgments to be paid on a periodic basis) Costs and Service Expenses (e.g., filing fees, hearing fees, trial fees, process fees) 1. $ per month, starting on the □ first day or □ Other: of the month following the date of the judgment until the total amount of $ is paid in full; or 2. A lump sum payment of $ to be paid by: (date). WHO PAYS □ Petitioner □ Respondent $ WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent Nine percent ( 9 %) per annum simple interest on the unpaid balance of the total judgment amount(s) of $ . Interest accrues from the date the judgment is entered and continues until fully paid. 1. $ per month, starting on the □ first day or □ Other: of the month following the date of the judgment until the total amount of $ is paid in full; or 2. A lump sum payment of $ to be paid by: (date). WHO PAYS □ Petitioner □ Respondent $ WHO RECEIVES □ Petitioner □ Respondent GENERAL JUDGMENT OF SEPARATION - PAGE 11 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com Attorneys Fees (if any) WHO PAYS □ Petitioner □ Respondent $ WHO RECEIVES □ Petitioner □ Respondent DATED this day of , 20 Circuit Court Judge Print Name APPLICATION FOR FULL CHILD SUPPORT PROGRAM SERVICES: By signing below, I apply for child support services, including enforcement, from the Child Support Program(CSP). Check the box in Paragraph 7(a) if you are requesting accounting and disbursement services only. (Note: If you never received TANF, tribal TANF or AFDC in any state, an annual $25 fee will apply if over $500 is collected and distributed to the family each year.) □ Petitioner, Signature Date □Respondent, Signature Date □ All parties have agreed (stipulated) to the terms of this judgment. Sign before a Notary Public or Court Clerk only. Petitioner, Signature State of County of ) ) This instrument was acknowledged before me on , 20 by , (date) (name of person). Notary Public for My Commission Expires: GENERAL JUDGMENT OF SEPARATION - PAGE 12 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) /Court Clerk American LegalNet, Inc. www.FormsWorkflow.com Respondent, Signature State of County of ) ) This instrument was acknowledged before me on by , 20 , (date) (name of person). _______________________________________ Notary Public for ______________/Court Clerk My Commission Expires:__________________ □ If applicable, child who is at least 18 and under 21 years of age, has agreed (stipulated) to the terms of this judgment: (sign only your name) Child, Signature State of County of ) ) This instrument was acknowledged before me on by , 20 , (date) (name of person). _______________________________________ Notary Public for ______________/Court Clerk My Commission Expires:__________________ 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: □ I selected this document for myself and I completed it without paid assistance. □ I paid or will pay money to for assistance in preparing this form. Submitted by: □ Petitioner □ Respondent, Signature Address or Contact Address Print Name City, State, Zip Telephone or Contact Telephone Certificate of Mailing. I certify that I mailed a copy of this judgment and attachments thereto by U.S. Mail with postage paid to the other party at the following address: on the following date: □ Petitioner □ Respondent, Signature Print Name I certify that this is a true copy: □ Petitioner □ Respondent, Signature GENERAL JUDGMENT OF SEPARATION - PAGE 13 OF 13 Separation-2A: Judgment2AVer11.doc (1/08) American LegalNet, Inc. www.FormsWorkflow.com