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 ) and ) ) □ , ) Child who is at least 18 and under 21 years ) of age, unmarried and unemancipated. ) (ORS 107.108) ) Case No. STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [With Children]; and MONEY AWARD 1. This matter came before the court: □ On the stipulations of the parties, as shown by the signatures below. □ The court has waived the 90 day waiting period because the parties have entered into a stipulated (agreed to) judgment. 2. Findings. The court considered the: □Affidavit and stipulations A. Irreconcilable differences have caused the irremediable breakdown of this marriage/domestic partnership. B. □ Spouses Only: Co-Petitioner, (write name) □Both Co-Petitioners has/have been a resident of or domiciled in the state of Oregon continuously for six months immediately prior to the filing of the Co-Petition for Dissolution of Marriage. □ 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 □ Co-Petitioner, (write name) 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), year(s) of birth(s) and age(s)): Name Year of Birth Age STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN] AND MONDEY AWARD - Page 1 of 14 American LegalNet, Inc. Co-Petitioners – 9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com Name Year of Birth □ Spouse/Partner (write name), been established, of other spouse/partner’s child/ren named Age is not the parent, or paternity has not born during the marriage/domestic partnership on the following date(s) □ Neither party is now pregnant. □ Co-Petitioner, (write name) , is now pregnant. □ Co-Petitioner, (write name) , □ is □ is not the parent of this/these 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. □ Oregon does not have jurisdiction under the Uniform Child Custody Jurisdiction Act because E. 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 marital/domestic partnership status of the parties shall terminate on the date this judgment is signed by the judge. 1. Parenting Plan. Custody of the child/ren is awarded as follows: □ Co-Petitioner, (write name) following child/ren (list names): is awarded sole custody of the . □ Co-Petitioner, (write name) following child/ren (list names): is awarded sole custody of the STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 2 of 14 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com □ The parties have agreed to joint custody of the following child/ren (list names): as described in the attached parenting plan, labeled, “Exhibit 1.” □ Co-Petitioner, (write name) should have parenting time with the child/ren in accordance with □ the local court rule, or □ the attached parenting plan, labeled, “Exhibit1.” should have reasonable parenting □ Co-Petitioner, (write name) 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.” □Co-Petitioner, (write name) shall not have parenting time because this would endanger the health and safety of the child/ren. □ Any cost of the □ Parenting time shall be supervised by supervision shall be paid by □Co-Petitioner, (write name) □ Other: . □ Co-Petitioners 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. 2. Cash Child Support. Complete either (a) or (b) below: (a) to □ Cash child support must be paid by □ Co-Petitioner □ Co-Petitioner beginning on the □ first or □ of the month following the date of the judgment and continuing on the same day for of each month thereafter. The total payment per month is $ children. The cash child support: □ Is the amount presumed to be appropriate under the support guidelines. □ Is different from the presumed appropriate amount of $ reasons) (b) because (list . □ No cash child support is ordered in this judgment because: □ An order, □ including medical support, for child support in the monthly amount of $ has already been ordered in Circuit Court case number County, Oregon. in □ Other reason: STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 3 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com 3. Medical Support. Complete section (a) or (b) below. Also complete section (c) or (d) below. Complete (a) or (b): (a) Private Health Care Coverage is Appropriate and Available. □ Co-Petitioner □ Both Co-Petitioners has/have appropriate private health care coverage available for the parties’ child/ren through an employer, spouse, domestic partner or other source. □ Co-Petitioner □ Both Co-Petitioner is/are ordered to obtain and/or maintain this coverage throughout the period of the support obligation for the benefit of the parties’ child/ren. □ Health care coverage is not ordered in this judgment because it has already been ordered in another case as described in section 2(b) above. (b) No Private Health Care Coverage is Appropriate or Available. □ Neither Co-Petitioner has appropriate private health care coverage available for the parties’ child/ren. □ Co-Petitioner □ Both Co-Petitioners must provide appropriate private health care coverage for the child/ren when such coverage becomes available to them at a reasonable cost through any source. □ The custodial parent shall enroll or maintain the child/ren in public health care coverage. Complete (c) or (d): (c) Cash Medical Support Ordered. □ Because the parent receiving cash child support is ordered to maintain private health care coverage and the parent paying cash child support is not ordered to maintain private health must insurance, in addition to cash child support □ Co-Petitioner pay $ for cash medical support to □ Co-Petitioner or □ Because neither parent has appropriate private health care coverage available for the parties’ child/ren: □ Co-Petitioner must pay cash medical support in to Co-Petitioner and/or the monthly amount of $ □ Co-Petitioner must pay cash medical support in the monthly amount of $ to Co-Petitioner. (d) Cash Medical Support Not Ordered. □ Cash medical support is not ordered for the following reasons: □ The parent paying cash child support is also providing health care coverage. □ Section (e) below requires the parties to share the cost of the child/ren’s uninsured medical expenses. ’s gross monthly income is at or below the □ Co-Petitioner Oregon minimum wage for full-time employment. □ Other reason: STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 4 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com (e) Responsibility for Uninsured Health Expenses. After the custodial parent pays the first $250 per year per child, □ Co-Petitioner must pay % and Co-Petitioner must pay % of the reasonably incurred uninsured health, accidental, dental, orthodontic, and optical costs incurred by the child/ren, including costs for prescriptions. This obligation is □ in addition to □ instead of any cash medical support ordered above in paragraph 3(c) as part of the child support award. 4. Length of Child Support. Unless the child becomes self-supporting, emancipated, or married: □ The support ordered in paragraphs 2 and 3 above for each child shall continue until the child reaches eighteen (18) years of age. □ The support ordered in paragraphs 2 and 3 above for each child shall continue until the child reaches age 21 if the child qualifies for support as a child attending school as defined by Oregon law. NOTICE ABOUT PERIODIC REVIEWS If you are receiving child support services through the Department of Justice, 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 a substantial change of circumstances. 5. 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 □ Co-Petitioner ’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. /// /// /// /// /// STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 5 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com NOTICE OF INCOME WITHHOLDING This child 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. 6. Dependents for Tax Purposes. □ Co-Petitioner 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): 7. Life Insurance Coverage for Child/ren. □ Co-Petitioner 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. 8. Spousal Support and Life Insurance. □ No spousal support or spousal life insurance is ordered in this case. □ The terms for Spousal Support, Payments, and Life Insurance indicated below shall be in effect: Spousal Support. Support shall be paid by: (write names) In the amount of:$ per month, or $ Period support payments shall last until: to by (date). , or the death of either party, STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 6 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com whichever comes first. The support shall be called (check one or more): □ transitional □ compensatory □ spousal maintenance, based on consideration of the following factors:: Spousal support payments are taxable to the obligee spouse/domestic partner and deductible to the obligor spouse/domestic partner. All payments terminate upon the death of either party. Judgment is entered accordingly. Payments. Payments shall be made on the first day of each month beginning the month following the date the judgment is signed by a judge. All payments of spousal support shall be made: (check (a) or (b)) (a) □ To the Department of Justice, Child Support Accounting Unit, P.O. Box 14506, Salem, Oregon, 97309. Co-Petitioner requests that collection, accounting, disbursement, and enforcement services be provided through the Department of Justice. (b) □ Directly into ’s checking or savings account. A receipt of deposit shall be kept by the paying spouse/domestic partner as proof of payment. The spouse/domestic partner receiving support should provide the paying spouse/domestic partner with current deposit slips and/or bank name, account name, and account number. Withholding. □ If child support is also ordered in this case and if enforcement services are provided through the State of Oregon’s Department of Justice, the spousal support order shall be enforceable by income withholding under ORS 25.381. Life Insurance. □Co-Petitioner, (write name) for the benefit of □Co-Petitioner, (write name) of the spousal support obligation in the amount of $ shall buy and maintain life insurance throughout the period 9. Real Property Distribution. □ Neither Co-Petitioner has any interest in any real property located in this or in any other state. □ Co-Petitioner, (write name) □ Both Co-Petitioners has/have an interest in real property located at the address of □ This property shall be distributed as follows: □ Additional page labeled “Paragraph 9 - Real Property Distribution continued” attached. □ The legal description of the property is attached as “Exhibit ____” and incorporated into this Judgment. □ Co-Petitioner, (write name) 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. /// /// /// STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 7 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com 10. Personal Property Distribution (including motor vehicles). □ The Co-Petitioners 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. □ Co-Petitioner, (write name) is awarded the following personal property: □ Additional page labeled “Paragraph 10 – Co-Petitioner, (write name) ’s Personal Property Distribution continued” attached. is awarded his/her retirement □ Co-Petitioner, (write name) benefits, pension plan, profit-sharing plan, deferred compensation plan, and/or stock option plan held by his/her current or past employer, free of any interest in the other party. □ Co-Petitioner, (write name) is awarded his/her retirement benefits, pension plan, profit-sharing plan, deferred compensation plan, and/or stock option plan held by his/her current or past employer, free of any interest in the other party. is awarded the following personal □ Co-Petitioner, (write name) property: □ Additional page labeled “Paragraph 10 - Co-Petitioner, (write name) Personal Property Distribution continued” attached. ’s 11. 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 (write names) □ Additional page attached, labeled “Paragraph 11 - Distribution of Debts continued”. Each party shall be responsible for the payment of all debts incurred by him/her individually since the date of the separation; all debts which are distributed to him/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 s/he does so, the spouse/domestic partner responsible for that debt shall reimburse the other spouse/domestic partner for any monies s/he paid to the creditor after the date this judgment was entered. The date of separation (when you began living apart) was: 12. 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. STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 8 of 15 Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) American LegalNet, Inc. www.FormsWorkFlow.com The judgment shall operate to convey title to the party awarded the property if the other party fails to comply with this requirement. 13. Former Name. □ Co-Petitioner’s former name of is restored. 14. Additional Provisions: □ Additional page attached labeled “Paragraph 14 - Additional Provisions continued”. 15. 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: □ Co-Petitioner (write name): □ 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 shall reimburse the other □ Co-Petitioner (write name), spouse/domestic partner 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. 16. 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. 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 below 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, the Department of Justice or the District Attorney shall not disclose the information in the following section to the other parent. □ Otherwise: Petitioner Respondent Full Name Former Legal Name(s) Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Age STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 9 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com Address or Contact Address Telephone Number Social Security Number Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Driver License Number Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Employer Name Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Do not list here. List the information on the UTCR 2.130 Confidential Information Form (CIF). Employer Address Employer Telephone □ Additional page labeled “Paragraph 16 - Required Information continued” attached. Date of marriage/domestic partnership: Place of marriage/domestic partnership: . . 17. Money Award. Child Support Obligation □ included □ not included. Spousal Support □ included □ not included. Additional information PETITIONER RESPONDENT Full Name Address or Contact Address Attorney’s Name, Telephone Number and Address (if applicable) Year of Birth Last Four Digits of Driver License Number and State of Issuance STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 10 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com Last Four Digits of the Support Obligor’s Social Security Number 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 $ □ per month, of which $ is cash medical support. Starting on □ the first day or (day) month following the date of the judgment of the 1. $ per month starting on □ the first day or of the month following the date of □ Other: , or the the judgment, lasting until (date) death of either party, whichever comes first; or 2. 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. STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD – Page 11 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) 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) WHO PAYS □ Petitioner □ Respondent per month, starting on the 1. $ □ 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 RECEIVES □ Petitioner □ Respondent WHO PAYS □ 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. WHO RECEIVES □ Petitioner □ Respondent WHO PAYS □ Petitioner □ Respondent WHO RECEIVES □ Petitioner □ Respondent 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 DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP; and MONEY American LegalNet, Inc. AWARD - Page 12 of 15 Disso-1B: StipJudg9A-Ver12.doc (9/10) 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 5(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.) □ Co-Petitioner Signature Date □Co-Petitioner Signature Date □ All parties have agreed (stipulated) to the terms of this judgment. (Sign before a notary public or court clerk only.) □Co-Petitioner, Signature State of County of ) ) This instrument was acknowledged before me on , 20 by (name of person(s)). , (date) Notary Public for My Commission Expires: /Court Clerk STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD - Page 13 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com □Co-Petitioner, Signature State of County of ) ) This instrument was acknowledged before me on , 20 , (date) by (name of person(s)). Notary Public for My Commission Expires: /Court Clerk □ 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 , 20 , (date) by (name of person(s)). Notary Public for My Commission Expires: /Court Clerk 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: □ Co-Petitioner, Signature Address or Contact Address Print Name City, State, Zip □ Co-Petitioner, Signature Address or Contact Address Telephone or Contact Telephone Print Name City, State, Zip Telephone or Contact Telephone STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD - Page 14 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com I certify that this is a true copy: ______________________________ □ Co-Petitioner Signature STIPULATED GENERAL JUDGMENT OF DISSOLUTION OF MARRIAGE/DOMESTIC PARTNERSHIP [WITH CHILDREN]; AND MONEY AWARD - Page 15 of 15 American LegalNet, Inc. Co-Petitioners -9A: StipJudg9A-Ver12.doc (9/10) www.FormsWorkFlow.com