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Use this template/form as a Divorce with Children Form in the State of Indiana

Indiana Divorce Form with Children


Text version of this Form

———————– Page 1———————–

1. What is the name of the County where you will be filing this divorce? ________________________

2. What is your full name?

____________________________________________________________

3. What is your street address?

____________________________________________________________

4. What is your town, state, and ZIP Code?

____________________________________________________________

5. What is your telephone number, with area code? ______________________

6. What is your email address? _________________________________

7. If you have a fax machine number and want to receive service by fax machine, what is your fax machine
number, with area code? ______________________

8. If you have used the Attorney General Confidental address in any related cases, select “X”: _____

9. What is your spouse’s full name?

____________________________________________________________

10. What is your spouse’s street address?

____________________________________________________________

11. What is your spouse’s town, state and ZIP Code?

____________________________________________________________

———————– Page 2———————–

12. Are there are other Court cases involving yourself and the other party? _____ Yes _____ No

13. If you selected “Yes,” for each case you and the other party are involved, what is the name of the Court and
Case Number. If you selected “No,” skip to the next question.

Caption:____________________________ Case Number: ________________________
Caption:____________________________ Case Number: ________________________
Caption:____________________________ Case Number: ________________________
Caption:____________________________ Case Number: ________________________
Caption:____________________________ Case Number: ________________________
Caption:____________________________ Case Number: ________________________

14. How many children do you and your spouse have together? ____________

15. What is the date that you and your spouse were married? ____________________

16. What is the date that you and your spouse were separated? ____________________

17. Type the name of the person (either you or your spouse) who has lived in the county you will be filing your
divorce in for at least the last three months and who has lived in the state of Indiana for at least the last six
months.

____________________________________________________________

18. What are the full names and birthdays of your children?

Full Name ______________________________ Birthday _________________
Social Security Number _________________

Full Name ______________________________ Birthday _________________
Social Security Number _________________

Full Name ______________________________ Birthday _________________
Social Security Number _________________

Full Name ______________________________ Birthday _________________
Social Security Number _________________

19. What is the full name of the spouse who you agree will have custody of the children?

____________________________________________________________

20. What is the name of the spouse who will pay child support?

____________________________________________________________

———————– Page 3———————–

21. Are there debts and property that need to be divided? Yes No

If “yes,” list them individually below:

a. _________________________________________________________________

b. _________________________________________________________________

c. _________________________________________________________________

d. _________________________________________________________________

22. Type the name of the wife in this blank ONLY if she is not pregnant.

____________________________________________________________

23. Does the wife want her former name restored? Yes No
If “yes,” what is the former name she wishes to have restored?

____________________________________________________________

24. Please check the box that describes your agreement for physical and legal custody of your children:

I will have sole physical and legal custody.

My spouse will have sole physical and legal custody.

I will have sole physical custody, but my spouse and I will have joint legal custody.

My spouse will have sole physical custody, but my spouse and I will have joint legal custody.

We have other arrangements: ___________________________________________________________

25. Please check the box that describes your agreement for visitation of your children:

My spouse shall have reasonable visitation as we agree or according to the Indiana Parenting Time
guidelines

I shall have reasonable visitation as we agree or according to the Indiana Parenting Time guidelines

We have other arrangements: ___________________________________________________________

Get out the Worksheet – Child Support Obligation form that you filled out earlier, on the page that is named
Child Support Obligation Worksheet (CSOW), look at the bottom of that page while you are answering
questions 26 through 30.

26. Line 8 is Recommended Child Support, what is the amount that it shows? _______________

27. In the section called Uninsured Health Care Expense Calculation, look at A. Custodial Parent Annual
Obligation, what is the total amount it shows? _________________

28. Look at B. Balance of Annual Expense to be Paid, what percentage does it show for Father? _______%

29. Look at B. Balance of Annual Expense to be Paid, what percentage does it show for Mother? _______%

30. What is the name of the spouse who will be paying for medical, dental, and optical insurance for the
children? ______________________________

———————– Page 4———————–

31. What are the names of the children who will have medical, dental, and optical insurance provided for by
the spouse listed in #30?

32. In regards to claiming the tax credits, exemptions, and deductions for your minor child(ren), who will be
claiming them for federal, state, and local income tax purposes on an annual basis?

I will claim the child(ren) every year

My spouse will claim the child(ren) every year

I will claim the child(ren) in the year ________, and every _______ year thereafter; my spouse will
claim the child(ren) in the year ________, and every _______ year thereafter

Other: ____________________________________________________________________________

33. Do you and your spouse have debt that still needs to be divided? Yes No

If you answered “yes,” for the debt you will be paying, please type the name of who is owed and how
much is owed.

Name: ______________________________ Amount: __________________

Name: ______________________________ Amount: __________________

Name: ______________________________ Amount: __________________

For the debt your spouse will be paying, type the name of who is owed and how much is owed.

Name: ______________________________ Amount: __________________

Name: ______________________________ Amount: __________________

Name: ______________________________ Amount: __________________

34. Do you and your spouse have vehicles that still need to be divided? Yes No

If you answered “yes,” please type the Make, Model and Year of the vehicle(s) that you will take
possession.

Vehicle #1: _______________________________________________

Vehicle #2: _______________________________________________

Please type the Make, Model and Year of the vehicle(s) that your spouse will take possession.

Vehicle #1: _______________________________________________

Vehicle #2: _______________________________________________

———————– Page 5———————–

35. Do you and your spouse have property that still needs to be divided? Yes No

If you answered “yes,” please list the property that you will take possession.

Please list the property that your spouse will take possession.

36. For service of this divorce packet, how do you want your spouse to be served? Please note, there is an
additional charge for service by Sheriff. You will need to talk to the Clerk to find the amount you will be
charged.

I want my spouse served by Certified Mail
I want my spouse served by Sheriff at their home address
I want my spouse served by Sheriff at their job, their employer name and address is:

________________________________________________________________________

You have finished answering the questions. The following pages are the forms that you will be
printing and then filing with the court. Please look over them to make sure the information is correct
before you print them out. If you have changes, you must make them to the questions above. Once
you have printed this packet, make sure you sign it on the Signature line. Your signature must be on
these forms before you make copies and file it with the court.

———————– Page 6———————–

STATE OF INDIANA ) IN THE _______________ SUPERIOR/CIRCUIT COURT
) SS:
COUNTY OF _______________ ) CASE NO. ______________________________

IN RE THE MARRIAGE OF:

______________________________
Petitioner,

V.

______________________________
Respondent.

APPEARANCE BY SELF-REPRESENTED PERSON IN CIVIL CASE

This Appearance Form must be filed on behalf of every party in a civil case.

1. My Name is: ___________________________________ and I am

Initiating (filing) X ;
Responding (answering or defending)_____; or
Intervening ____;

in this case and am representing myself.

2. Contact information for receiving legal service of documents and case information is required by
Court Rules: (NOTE: If you are the Initiating party and this case, or a related case, involves a
protection from abuse order, a workplace violence restraining order, or a no-contact order, you must
provide an address for the purpose of legal service of documents but that address should not be one that
exposes the whereabouts of a petitioner)

Address: _____________________________________
_____________________________________________
Email Address: ________________________________
Phone: _______________________________________
FAX: ________________________________________

OR, if in the related case, you have used the Attorney General Confidential address, you may check the
box below:

____ Attorney General confidential address (contact the Attorney General at 1-800-321-1907 or
e-mail address is confidential@atg.state.in.us).

3. This is a __________ case type as defined in administrative Rule 8(B)(3).
(Clerk will supply this information.)

4. I will accept service by FAX at the following number _________________________

Page 1 of 2 Form TCM-TR3.1-2
Revised by State Court Administration 10/10

———————– Page 7———————–

5. This case is a domestic relations matter, involves reciprocal enforcement of support, paternity,
delinquency, Child in Need of Services (CHINS), guardianship, or any other proceedings in which
support may be an issue, and social security numbers of all family members are supplied on a separately
attached document (Form TCM-TR3.1-4) filed as confidential information on light green paper.

X Yes ______ No

6. There are related cases: Yes____ No ____ (If yes, please indicate below.)

Caption and case number of related cases:

Caption:____________________________ Case Number: ________________________

Caption:____________________________ Case Number: ________________________

Caption:____________________________ Case Number: ________________________

Caption:____________________________ Case Number: ________________________

Caption:____________________________ Case Number: ________________________

Caption:____________________________ Case Number: ________________________

7. Additional information required by local rule:

_________________________________________________________________________

____________________________________
Self-Represented Party

Page 2 of 2 Form TCM-TR3.1-2
Revised by State Court Administration 10/10

———————– Page 8———————–

NOT FOR PUBLIC ACCESS
IN ACCORDANCE WITH ADMINISTRATIVE RULE 9

ATTENTION CLERK: FOR SELF REPRESENTED LITIGANTS, TREAT THIS FORM AS IF IT IS PRINTED ON LIGHT GREEN PAPER

ATTORNEYS MUST SUBMIT THIS FORM ON LIGHT GREEN PAPER. SEE BOTTOM OF PAGE FOR TEXT OF TRIAL RULE 5 (G) (2)

STATE OF INDIANA ) IN THE _______________ SUPERIOR/CIRCUIT COURT
) SS:
COUNTY OF _______________ ) CASE NO. ______________________________

IN RE THE MARRIAGE OF:

______________________________
Petitioner,

V.

______________________________
Respondent.
CIVIL APPEARANCE FORM

Item 5 (Social Security numbers of all family members in cases involving support):

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Name: _________________________________ SS # _________________________

Item 8 (Social Security number of person who is subject to involuntary commitment):

Name: _________________________________ SS # _________________________

When only a portion of a document contains information excluded from public access pursuant to
Administrative Rule 9(G)(1), said information shall be omitted [or redacted] from the filed document and set
forth on a separate accompanying document on light green paper conspicuously marked “Not For Public
Access” and clearly designating [or identifying] the caption and number of the case and the document and
location within the document to which the redacted material pertains.

NOT FOR PUBLIC ACCESS

Page 1 of 1 Form TCM-TR3.1-4
Approved by State Court Administration 07/09

———————– Page 9———————–

STATE OF INDIANA ) IN THE SUPERIOR/CIRCUIT COURT
) SS:
COUNTY OF ) CASE NO.

IN RE THE MARRIAGE OF:

Petitioner,

V.

Respondent.

VERIFIED PETITION FOR DISSOLUTION OF MARRIAGE

The Petitioner, ____________________________________________________________, now states:

1. Petitioner and Respondent were married on _________________, and separated on
_________________.

2. ____________________________________________________________ has been a
continuous resident of ________________ County for the last 3 months.

3. ____________________________________________________________ has been a
continuous resident of the State of Indiana for the last 6 months.

4. There are __________ children of the marriage; namely:

Name Date of birth

______________________________ _________________

______________________________ _________________

______________________________ _________________

______________________________ _________________

5. That ____________________________________________________________ is fit and proper
person to have custody of the minor children.

6. Debts and property:

There are no debts / personal property to divide.

Page 1 of 2 Form PS-31152-1
Approved by State Court Administration 07/09

———————– Page 10———————–

Petitioner wishes the Court to divide the following debts / personal property:

a. _________________________________________________________________

b. _________________________________________________________________

c. _________________________________________________________________

d. _________________________________________________________________

7. __________________________________________________ is not pregnant.

8. Neither party is a member of the military.

9. This marriage has suffered an irretrievable breakdown and should be dissolved.

10. Change of name:

Wife would like her former name of ______________________________ restored to her.

Wife does not want to change her name.

I affirm under the penalties of perjury that the foregoing representations are true.

_________________________
Signature

Page 2 of 2 Form PS-31152-1
Approved by State Court Administration 07/09

———————– Page 11———————–

STATE OF INDIANA ) IN THE SUPERIOR/CIRCUIT COURT
) SS:
COUNTY OF ) CASE NO.

IN RE THE MARRIAGE OF:

Petitioner,

V.

Respondent.
VERIFIED WAIVER OF FINAL HEARING

Come now Petitioner and Respondent pursuant to Ind. Code 31-1-11.5-8 and submit their
Verified Waiver of Final Hearing. In support of this Waiver, the parties state that:

1. More than sixty (60) days have elapsed since the filing of Petitioner’s Verified Petition for
Dissolution of Marriage;

2. Both parties request the Court to approve their Settlement Agreement and Decree of Dissolution
of Marriage.

3. Both parties voluntarily waive the opportunity to hold a final hearing on contested issues.

I affirm under the penalties of perjury that the foregoing representations are true.

_____________________________ _______________________________
Your Signature Your Spouse’s Signature

Page 1 of 1 Form PS-31152-2
Approved by State Court Administration 07/09

———————– Page 12———————–

STATE OF INDIANA ) IN THE SUPERIOR/CIRCUIT COURT
) SS:
COUNTY OF ) CASE NO.

IN RE THE MARRIAGE OF:

Petitioner,

V.

Respondent.

DECREE OF DISSOLUTION OF MARRIAGE AND SETTLEMENT AGREEMENT

The parties having submitted their Settlement Agreement and the court having seen and considered the
Verified Petition for Dissolution of Marriage and Verified Waiver of Final Hearing submitted by the
parties, now approves the following agreement:

1. The parties were married on _________________, and separated on ________________.

2. ____________________________________________________________ has been a
continuous resident of ___________________ County for the last three months, and the State of Indiana
for the last six months prior to the filing of the Verified Petition for Dissolution of Marriage.

3. ____________________________________________________________ is not pregnant.

4. Neither party is a member of the military.

5. There were children born of this marriage; namely;

Name Date of birth

______________________________ _________________

______________________________ _________________

______________________________ _________________

______________________________ _________________

6. The parties agree and state that it is in the best interest of the child(ren) that:

Petitioner shall have sole physical and legal custody of the child(ren).

Respondent shall have sole physical and legal custody of the child(ren).

Petitioner shall have sole physical custody and the parties shall have joint legal custody
of the child(ren)

Page 1 of 5 Form PS-31152-3
Approved by State Court Administration 07/09

———————– Page 13———————–

Respondent shall have sole physical custody and the parties shall have joint legal custody
of the child(ren).

Other: ___________________________________________________________

7. The parties have agreed on the following Parenting Time (Visitation) order:

Petitioner shall have reasonable visitation with the minor child(ren) as the parties agree or
according to the Indiana Parenting Time guidelines.

Respondent shall have reasonable visitation with the minor child(ren) as the parties agree
or according to the Indiana Parenting Time guidelines.

Other: ___________________________________________________________

8. ____________________________________________________________ will pay child support
in the amount of _______________ per week, as shown by the attached child support worksheet,
through the County Clerk’s office, or by income withholding order if available from the employer,
beginning on the first Friday following the date of the decree. Said date is _________________.
____________________________________________________________ will be responsible for the
first __________________ of uninsured medical expenses for the minor child(ren). Thereafter, Father
shall be responsible for _______% of uninsured medical expenses, and Mother shall be responsible for
_______% of uninsured medical expenses for the minor child(ren).

9. The parties have agreed on the following provisions for health insurance maintenance:

____________________________________________________________ shall maintain
medical, dental, and optical insurance as available through employment on the minor child(ren):

10. The parties have agreed on the following arrangement for claiming the tax credits, exemptions,
and deductions for the minor child(ren):

Petitioner shall be entitled to claim the minor child(ren) for federal, state, and local
income tax purposes on an annual basis; Respondent shall sign all necessary documents
that will entitle Petitioner to do so.

Respondent shall be entitled to claim the minor child(ren) for federal, state, and local
income tax purposes on an annual basis; Petitioner shall sign all necessary documents
that will entitle Respondent to do so.

Petitioner and Respondent shall each be entitled to claim the minor child(ren) for federal,
state, and local income tax purposes in alternating years; Petitioner shall be entitled to
claim the minor child(ren) in the year ________, and every _______ year thereafter;
Respondent shall be entitled to claim the minor child(ren) in the year ________, and
every _______ year thereafter.

Other: ___________________________________________________________

Page 2 of 5 Form PS-31152-3
Approved by State Court Administration 07/09

———————– Page 14———————–

11. The parties have agreed on the following debt division:

The parties already have divided their debts.

Petitioner will be solely responsible for and shall hold Respondent harmless from, the
following debts:

Name of Creditor Amount of Debt

______________________________ __________________

______________________________ __________________

______________________________ __________________

Respondent will be solely responsible for, and shall hold Petitioner harmless from the
following debts:

Name of Creditor Amount of Debt

______________________________ __________________

______________________________ __________________

______________________________ __________________

12. The parties have agreed on the following vehicle division:

There are no vehicles to divide.

Petitioner will have sole possession of the following vehicles, and Respondent shall
execute all documents necessary to transfer title of said vehicles within thirty (30) days of
the date of this Order:

_______________________________________________
Vehicle #1, Make, Model, and Year

_______________________________________________
Vehicle #2, Make, Model, and Year

Page 3 of 5 Form PS-31152-3
Approved by State Court Administration 07/09

———————– Page 15———————–

Respondent will have sole possession of the following vehicles, and Petitioner shall
execute all documents necessary to transfer title of said vehicles within thirty (30) days of
the date of this Order:

_______________________________________________
Vehicle #1, Make, Model, and Year

_______________________________________________
Vehicle #2, Make, Model, and Year

13. The parties have agreed on the following property division:

The parties already have divided all items of property.

Petitioner will have sole possession of the following items of property:

Respondent will have sole possession of the following items of property:

14. The marriage has suffered an irretrievable breakdown and should be dissolved.

15. Change of names:

Wife would like her maiden name or previous married name of
__________________________________________________________ restored to her.

Wife does not want to change her name.

The parties have disclosed all relevant documents and exchanged all information on value of property,
pensions, real estate, and other assets and debts. The parties agree that this division of property is/is not
an approximate equal division of the assets and debts. The parties agree that if this division is not a
nearly equal division, that the deviation from the presumptive equal division should be accepted by the
Court because it is the parties’ agreement and neither party has been forced or threatened to accept this
agreement.

I affirm under the penalties of perjury that the foregoing representations are true.

____________________________
Your Signature

Page 4 of 5 Form PS-31152-3
Approved by State Court Administration 07/09

———————– Page 16———————–

STATE OF INDIANA )
) SS:
COUNTY OF ____________)

Before me, ______________________________, a notary public in and for ________________
County, State of Indiana, personally appeared ______________________________, and he/she being
first duly sworn upon his/her oath, says that the facts alleged in the foregoing instrument are true.
Date ________________ __________________________________
Notary Public
MY COMMISSION EXPIRES:
_________________________

______________________________
Your Spouse’s Signature

STATE OF INDIANA )
) SS:
COUNTY OF ____________)

Before me, ______________________________, a notary public in and for ________________ county,
State of Indiana, personally appeared ______________________________, and he/she being first duly
sworn upon his/her oath, says that the facts alleged in the foregoing instrument are true.
Date ________________ __________________________________
Notary Public
MY COMMISSION EXPIRES:
_________________________

IT IS THEREFORE ORDERED by the Court that the parties’ marriage is hereby dissolved, and the
terms of their agreement as set out above shall be incorporated into this Order.

________________________________ _________________________________
Date Judge

Distribution:

Page 5 of 5 Form PS-31152-3
Approved by State Court Administration 07/09

———————– Page 17———————–

STATE OF INDIANA ) IN THE SUPERIOR/CIRCUIT COURT
) SS:
COUNTY OF ) CASE NO.

IN RE THE MARRIAGE OF:

Petitioner,

V.

Respondent.

SUMMONS
[For Dissolution of Marriage Cases Only]

The State of Indiana to Respondent: _______________________________________________
_______________________________________________
_______________________________________________

You have been sued by your spouse for dissolution of your marriage. The case is pending in the
Court named above.
In order to participate in the proceedings, you must enter a written appearance in person or by
your attorney. In the event you do not enter a written appearance within sixty (60) days of the date
hereof, your marriage can be dissolved by Decree of the Court by default. In the event a Decree is
entered by default, it may contain a judgment against you and provisions regarding the custody of your
child/children, support for your child/children, parenting time (visitation) with your child/children,
distribution of assets, and payment of debts. The Decree may also require you to take actions or refrain
from actions in order to carry out the terms of the Court’s Decree. If you do not enter a written
appearance, you will receive no further notice of these proceedings.
If you wish to countersue, you must do so by written petition filed herein not more than sixty
(60) days from the date hereof.

Dated: _________________ __________________________________
Clerk, __________________ County

The following manner of Service of Summons is hereby designated:
Registered / Certified Mail to be sent by the Clerk
Service by Sheriff on Individual at address shown above
Service by Sheriff at place of employment, (name and address of spouse’s employer):

________________________________________________________________________

Page 1 of 2 Form TCM-TR4.1-2
Approved by State Court Administration 07/09

———————– Page 18———————–

SHERIFF’S RETURN OF SERVICE OF SUMMONS

I hereby certify that I have served this summons on the _____ day of _________________, 20____:

1. By delivering a copy of the Summons and a copy of the Petition to the Respondent

identified on the first page of Summons.

2. By leaving a copy of the Summons and a copy of the Petition at

_______________________________________, which is the dwelling place or usual place of abode of

and by mailing a copy of the Summons to the Respondent at the above address.

3. Other Service or Remarks: _________________________________________

_________________________ _____________________________________
Sheriff’s Costs Sheriff
By: _______________________________
Deputy

CLERK’S CERTIFICATE OF MAILING
I hereby certify that on the ______ day of ________________, 20___, I mailed a copy of this

Summons and a copy of the Petition to the Respondent identified on the first page of the Summons by

(registered or certified mail), [ ] requesting a return receipt, at the address provided by the Petitioner.

_____________________________
Clerk, __________________ County
Dated: ______________, 20____ By: _________________________
Deputy

RETURN ON SERVICE OF SUMMONS BY MAIL

I hereby certify that the attached receipt was received by me showing that the Summons and a

copy of the Petition mailed to the Respondent identified on the first page of this Summons was accepted

by the Respondent on the _______ day of __________________, 20____.

I hereby certify that the attached return receipt was received by me showing that the Summons

and a copy of the Petition was returned not accepted on the ______ day of __________________,

20____.

I hereby certify that the attached return receipt was received by me showing that the Summons

and a copy of the Complaint mailed to the Respondent identified on the first page of this Summons was

accepted by __________________________ on behalf of the Respondent on the _____ day of

______________, 20____.

_____________________________
Clerk, __________________ County
By: _________________________
Deputy

Page 2 of 2 Form TCM-TR4.1-2
Approved by State Court Administration 07/09

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