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. PETITION FOR SEPARATION DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 CLAIM □ SUBJECT □ NOT SUBJECT TO MANDATORY ARBITRATION 1. Date of marriage/domestic partnership: . (County, State) 2. (Check the box/es that apply) □ Irreconcilable differences between the Petitioner and Respondent have caused a temporary or unlimited breakdown of the marriage/domestic partnership. □ The parties have entered into an agreement that will be filed with the court suspending for a period not less than one year our obligation to live together as husband and wife/domestic partners and Respondent. □ Irreconcilable differences exist between the parties and the continuation of the marriage/domestic partnership preserves or protects their legal, financial, social or religious interests. of . Place of marriage/domestic partnership: 3. Certificate of Residency. 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. 4. The □ Petitioner □ Respondent is an Oregon resident. PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 1 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com 5. By filing this petition, I acknowledge that I am bound by the terms of the statutory restraining order prohibiting either party from disposing of marital/parnership assets, a copy of which I have received and read, and understand that this restraining order is effective immediately upon service of this petition and the summons upon the Respondent. 6. Children Born to Both Parties. Name Date of Birth Social Security No. Address Do not list. Provide by UTCR 2.100 Affidavit Do not list. Provide by UTCR 2.100 Affidavit Do not list. Provide by UTCR 2.100 Affidavit □ Additional page attached; see section labeled “Paragraph 6 continued.” □Petitioner □ Respondent is pregnant. □ Petitioner □ Respondent □ is □ is not the parent of this child. The expected date of the child’s birth is . □ Neither party is now pregnant. 7. Child/ren Born During Marriage/Domestic Partnership. List any child/ren born during the marriage/domestic partnership that spouse/domestic partners is not the parent of, and that were not conceived when husband and wife/domestic partners were living together: (name/s and date/s of birth) 8. UCCJEA Information. □ The child/ren listed above has/have continuously resided in Oregon for the six months preceding the filing of this case. List the places where the minor child/ren of the parties have lived in the last five years and the names of the people they lived with at that time. Dates From/To County, State Parent(s)/Caretaker Current Address/ Contact Address of Parent/Caretaker Which Children □ Additional page attached; see section labeled “Paragraph 8 continued.” I □ have □ have not participated in any litigation concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following litigation: Name of Court State Case No. Date Result PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 2 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com I do not know of any other domestic violence, custody, visitation, parenting time or placement proceeding involving the child/ren, or of any other court case which could affect this case, pending in this or any other state □ except for: (identify court, case number and the kind of proceeding) I do not know any person other than my spouse who has physical custody of the child/ren or who claims to have custody, visitation or parenting time rights □ except for: (list name and address) 9. Parenting Plan (Custody and Parenting Time). Custody of the child/ren should be awarded as follows: □ Respondent should be awarded sole custody of the following child/ren (list names): □ Petitioner should be awarded sole custody of the following child/ren (list names): □ The parties have agreed to joint custody of the following child/ren (list names): □ Petitioner □ Respondent should have parenting time with the child/ren □ as set forth in the attached Parenting Plan, labeled Exhibit , or □ Other: □ Petitioner □ Respondent should not be granted parenting time because this would endanger the health and safety of the child/ren. State supporting facts: □ Parenting time should be supervised by □ Any cost of the supervision shall be paid by □ Petitioner □ Respondent □ Other: □ Petitioner and Respondent should 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. □ Petitioner should be allowed to move more than 60 miles further distant from the other parent without advance notice because good cause exists. 10. Child Support, including Health Care Coverage and Cash Medical Support. A. Other Pending Child Support Cases. (Check one.) □ No other agency or court child support proceeding is currently pending (include any child support matter being heard as part of a dissolution, separation, annulment, paternity, support or modification case). □ There is/are other child support proceeding(s) currently pending in either an agency or court case as set forth in the CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDING and/or EXISTING CHILD SUPPORT ORDER attached to this petition. /// /// PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 3 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com B. Other Child Support Orders. (Check one.) □ No other child support orders, from an agency or court, are currently in effect in the State of Oregon or any other state. □ There is/are other child support orders from an agency or court as set forth in the CERTIFICATE RE: PENDING CHILD SUPPORT PROCEEDING and/or EXISTING CHILD SUPPORT ORDERS/JUDGMENTS attached to this petition. C. Currently Effective Child Support Order. (Check any that apply.) □ The following child support order/s is/are currently in effect: (List state, court/agency, case number, date of order) □ This order should remain in place, □ and includes provisions for health care coverage for the child/ren, or □ This order is from an Oregon court or agency, one of the parents or the child/ren receiving support still resides in Oregon and the order should be changed because circumstances have changed since the last order was entered. State facts showing how circumstances have changed: D. Child Support in this Case. □ No child support should be ordered in this case because: □ Child support has already been ordered as described in “C” above and this order should remain in place. □ Other reason: □ Child support should be paid by □ Petitioner to Respondent OR □ Respondent to Petitioner beginning on the first day of the month following the date of the judgment and continuing on the first (1st) day of each month thereafter. Under the Support Guidelines set out in Oregon’s Administrative Rules, the total payment of child support per month should be: □$ for children, □ as reflected in the attached Worksheets, or □ determined prior to judgment. If a specific amount is indicated above, that amount: □ does not deviate from the amount presumed correct under the guidelines. □ does deviate from the amount presumed correct under these guidelines because application of the formula would be unjust or inappropriate in this case because of (check one or more that apply): □ Recurring medical expenses (describe): □ Other: □ includes Cash Medical Support □ for out-of-pocket medical expenses exceeding $250 per year per child in the amount of $ and/or □ To reimburse for public health care costs in the amount of $ . (Check if applicable) □ Petitioner □ Respondent and/or □ Child/ren are eligible for public medical assistance and should not be ordered to pay cash medical support. /// PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 4 OF 9 www.FormsWorkflow.com Separation-2A: Petition2AVer07.doc (1/08) □ All payments of child support should be made to the Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309 □ by electronic payment withdrawal (EPW) or electronic funds transfer (EFT). In addition, support for a child attending school (between the ages of 18 and 21) as defined by Oregon law shall be distributed by the Department of Justice directly to the child subject to ORS 107.108. □ (Applies only if support enforcement services are not being provided.) Petitioner requests an exception to the income withholding requirement of ORS 25.378 allowing payment to be made directly to □ Petitioner’s □ Respondent’s checking or savings account. A receipt of deposit should be kept by the parent paying support as proof of payment. The parent receiving support should provide the paying parent with current deposit slips and/or bank name, account name, and account number. E. Health Care Coverage. (DO NOT FILL THIS SECTION OUT if you have marked the boxes in Paragraph 10(C) above, stating that you have a currently effective child support order that includes health care coverage and you are requesting that order remain in place.) 1.) PRIVATE INSURANCE IS AVAILABLE A.) THROUGH ONE PARENT □ Petitioner or □ Respondent has/have appropriate 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): I request that □ Petitioner □ Respondent be ordered to maintain this coverage throughout the period of the support obligation for the benefit of the parties’ child/ren. B.) THROUGH BOTH PARENTS □ Both Petitioner and Respondent have appropriate private health care coverage available for the parties’ child/ren. I select the following health care coverage to be maintained throughout the period of the support obligation: □ Petitioner’s □ Respondent’s □ Both Petitioner’s and Respondent’s (describe type/s of coverage): 2.) NO PRIVATE INSURANCE IS AVAILABLE NOW □ Neither Petitioner nor Respondent has appropriate private health care coverage available for the parties’ child/ren A.) □ Petitioner □ Respondent □ Both Petitioner and Respondent should be ordered to apply for and enroll the child/ren in public health care coverage. B.) □ Petitioner □ Respondent 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. C.) □ The child/ren are currently enrolled in public health care coverage. This coverage should be maintained. D.) □ Both Petitioner and Respondent should be ordered to provide appropriate private health care coverage when such coverage becomes available to them through any source. 3.) RESPONSIBILITY FOR UNINSURED HEALTH EXPENSES □ Petitioner should pay % □ and Respondent should pay % of the uninsured HEALTH, ACCIDENT, DENTAL, ORTHODONTIC, AND OPTICAL HEALTH costs incurred by the child/ren. This obligation is in addition to any cash medical support requested in paragraph 10(D) as part of the child support award. PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 5 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com F. (Check one.) □ 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 □ Other (specify): G. The support payments for each child should continue until the child reaches 18 years 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. 11. Life Insurance Coverage for Child/ren. □ Petitioner □ Respondent should obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation. The coverage should be in the amount of $ . 12. Additional Provisions. □ Additional page attached; labeled “Paragraph 12 Continued - Additional Provisions.” 13. Spousal Support and Life Insurance. □ No spousal support or spousal life insurance claims are made in this case. □ Additional sheet inserted; see Supplemental Petition labeled, “Spousal Support and Life Insurance.” 14. Real Property. □ Neither Petitioner nor Respondent has any interest in any real property located in this or any other state. □ Petitioner □ Respondent has/have an interest in real property located at the address of: This property should be distributed: □ equitably, or □ as follows: □ Additional page labeled “Paragraph 14 - Real Property continued” attached. □ The legal description of the real property is attached as Exhibit ___ and incorporated in this petition. □ Distribution of this property is not within the jurisdiction of this court. /// /// /// /// /// /// PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 6 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com 15. Personal Property (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 neither should claim those items now in possession of the other. The Petitioner should be awarded: □ an equitable distribution of the parties’ personal property, or □ the following personal property: □ Additional page labeled “Paragraph 15 - Petitioner’s Personal Property Distribution continued” attached. □ The Petitioner should be awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred-compensation plan, and /or stock option plan held by Petitioner’s employer, free of any interest in the Respondent. The Respondent should be awarded: □ an equitable distribution of the parties’ personal property, or □ the following personal property: □ Additional page labeled “Paragraph 15 - Respondent’s Personal Property Distribution continued” attached. □ The Respondent should be awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred-compensation plan, and/or stock option plan held by Respondent’s employer, free of any interest in the Petitioner. □ Additional page attached; see section labeled “paragraph 15 continued.” 16. Distribution of Debts. □ There are no outstanding debts of this marriage/domestic partnership. □ The debts should be paid as follows: Name of Creditor (who debt is owed to) What debt is for Amount Who should pay (Petitioner or Respondent) □ Additional page attached, labeled, “Paragraph 16 continued”. Each spouse/partner should be responsible for the payment of all debts incurred by him/her individually since the date of their separation; all debts which are distributed to him/her by the court; and all debts which are secured by property distributed to that spouse/partner. Also, if any creditor asks the spouse/partner not responsible for a debt to pay all or a portion of it, and he or she does so, the spouse/partner responsible for that debt should reimburse the other spouse/partner for any monies he/she paid to the creditor after the date of the judgment. PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 7 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com 17. Transfer of Debts and Property. Within 30 days of the date of judgment, each party should execute, acknowledge, and deliver whatever documents are necessary to accomplish the distribution of debts and property ordered by the court. The judgment should operate to convey title to the spouse/partner awarded the property if the other spouse/partner fails to comply with this requirement. 18. 19. Former Name. □ ’s former name of should be restored. Duration. □ The separation should be □ unlimited □ for a period of (fill in amount of time) 20. Information Required by ORS 25.020 and ORS 107.085. □ Disclosure of the following information would unreasonably put to risk the health, safety, or liberty of □ Petitioner □ Respondent or a child for the following reasons: □ Otherwise: (Fill out the information in the table below) Petitioner Respondent Full Name Former Legal Name(s) Age Address or Contact Address Telephone Number Social Security Number Do not list. Provide by UTCR 2.100 Affidavit. Do not list. Provide by UTCR 2.100 Affidavit. Drivers License Number Employer Name Employer Address Employer Telephone □ Additional page labeled “Paragraph 20 continued” attached. /// /// /// /// /// /// /// PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 8 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com 21. Court Costs and Fees. A. Deferred Costs and Fees Any court costs and service fees (if service is completed by the Sheriff) that are deferred (required to be paid at a later date) by the court should be paid by: □ Petitioner □ Respondent □ Both parties equally □ Other: B. Costs and Fees Paid by the Parties □ Each party should be responsible for paying his or her own court costs and service fees for this case. □ To be paid by both parties equally □ Petitioner □ Respondent should reimburse the other party for his/her court costs and service fees for this case. □ Other: Judgment should be entered according to the cost and fee allocation listed above. 22. 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. WHEREFORE, Petitioner requests a Judgment granting the relief asked for above, and other equitable relief that the Court thinks is just. STATE OF ) ) ss. County of ) I, , being duly sworn, say that I am the petitioner in this matter and that the foregoing petition is true and correct to the best of my knowledge. Petitioner (signature) Print Name Address or Contact Address City, State, Zip Code 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) PETITION FOR SEPARATION – DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS 21.111 American LegalNet, Inc. PAGE 9 OF 9 Separation-2A: Petition2AVer07.doc (1/08) www.FormsWorkflow.com