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Free Minnesota Joint Petition for Marriage Dissolution with Children Form - PDF Form Download

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Use this template/form as a Joint Petition for Marriage Dissolution with Children Form in the State of Minnesota


Minnesota Joint Petition for Marriage Dissolution With Children

Text version of this Form

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State of Minnesota District Court
County of: Judicial District:

Court File Number:
Case Type: Dissolution with Children

In Re the Marriage of:

,
Name of Husband (First, Middle, Last)

Joint Petition, Agreement, and
and Judgment and Decree for
Marriage Dissolution
With Children
.
Name of Wife (First, Middle, Last)

1. Information about Husband:

Full Name:
First Middle Last

Address:
Street Address Apt. No.

City County State Zip Code

Date of Birth: __________________________
Month Day Year

Husband’s former or other names:
(Or write “none) First Middle Last

Husband’s social security number is listed on Confidential Form 11.1 and submitted
along with the Joint Petition.

2. Information about Wife:

Full Name:
First Middle Last

Address:
Street Address Apt. No.

City County State Zip Code

Date of Birth: __________________________
Month Day Year

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Wife’s former or other names:
(Or write “none”) First Middle Last

First Middle Last

Wife’s social security number is listed on Confidential Form 11.1 and submitted along
with the Joint Petition.

3. Our Marriage

Husband and Wife were married on: (month, day, year)

in the City of , County of , State

of , Country of

4. 180 Day Requirement

Husband has been living in Minnesota for the past six (6) months: YES NO

Wife has been living in Minnesota for the past six (6) months: YES NO

5. Armed Forces

Husband is an active duty member of the armed forces: YES NO

If YES, has the member of the armed forces been stationed in Minnesota for the past six

(6) months? YES NO

Wife is an active duty member of the armed forces: YES NO

If YES, has the member of the armed forces been stationed in Minnesota for the past six

(6) months? YES NO

6. Marriage Cannot be Saved

There has been an irretrievable breakdown of our marriage relationship.

7. Physical Living Situation

Do Husband and Wife live together at this time? YES NO

If NO, the date of separation was: .
Month Day Year
If YES , Husband and Wife are living together at this time because:

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8. Other Proceedings

a. A separate court case for dissolution, legal separation, annulment, custody, parenting

time, or paternity has already been started by Husband or Wife in Minnesota or another

state: YES NO. If YES, the type of court case is:

and it was started in County in the State of

and the Court file number is , and the outcome of the case

is: Open Closed Unknown or .

b. Has a County started a Support case involving the Husband and the Wife or their

children? YES NO. If YES, the case was started in

County in the State of and the Court file number is

. The case is Dismissed Pending an Order for Support was

issued.

9. Protection or Harassment Order

a. An Order for Protection or a Harassment/Restraining Order is in effect regarding

Husband and Wife: YES NO. If YES, the Order protects: Husband

Wife the child(ren). The Order was filed in County

on , and the Court file number is

Month Day Year

A copy of the Order is submitted along with this Joint Petition.

b. If an Order for Protection is in effect, does the Order for Protection include a child

support obligation? YES NO

10. Juvenile Court Case

A Juvenile Court case (child protection, delinquency or foster care) involving husband ’s

and wife’s child(ren) has taken place in Minnesota or another state. YES NO

If YES, the case is in County in the State of _________________

and the Court file number is . The name of the child or

children involved in the Juvenile Court case is:

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11. Children Husband and Wife have Together (Joint Children)
“Child” means a living person under age 18, or under age 20 and still in high school.

a. List all joint children born before the marriage or born or adopted during the

marriage. If there are no joint children, or if Wife is not currently pregnant, you are using

the wrong form. Use Joint Petition, Agreement and Judgment and Decree Without

Children.

Full Name of Child Date of Age Child Currently Lives With
Birth
Husband Wife Both parents
OR
________________________________
(write in name)
Husband Wife Both parents
OR
________________________________
(write in name)
Husband Wife Both parents
OR
________________________________
(write in name)
Husband Wife Both parents
OR
________________________________
(write in name)
Husband Wife Both parents
OR
______________________________
(write in name)

The social security number of the child(ren) is/are listed on Confidential Form 11.1 and
submitted along with the Joint Petition.

If a child is living with someone other than a parent, write the child’s address below :

Address:________________________________________________________________
Street Address Apt. No.

City County State Zip Code

b. Has each child born to or adopted by husband and wife together lived in Minnesota

for the past six (6) months? YES NO

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If NO, name the child or children, name the State(s) the child has lived in during the past 6

months, and the dates the child lived in each state:

12. Adult Dependent Children : Child support may be ordered for a joint child over the age of 18 who

cannot support him/herself because of a physical or mental condition.

Is there an adult joint child born to or adopted by Husband and Wife who is not able to

support himself or herself because of a physical or mental condition? YES NO

If YES, the full name, date of birth and age of each adult dependent is:

Full Name of Dependent Date of Birth Age

The social security number of the adult dependent child(ren) is / are listed on
Confidential Form 11.1 and submitted along with the Joint Petition.

13. Pregnancy

Is wife pregnant? YES NO

If wife is pregnant answer (a) and (b):

a. The date the baby is due is

Month Day Year

b. Do Wife and Husband agree that husband is the biological father of the unborn child?

YES NO

If NO, Wife Husband claims husband is not the biological father of the child.

14. Husband’s Children from Other Relationship (Nonjoint Children)

Does Husband have minor child(ren) from another marriage or relationship?

YES NO If YES, the full name, date of birth and age of each child is:

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Full Name of Date of Does Child Live Is Husband Court-Ordered to
Child and Age Birth with Husband? pay Child Support for this Child?
YES NO YES NO

YES NO YES NO

YES NO YES NO

YES NO YES NO

15. Wife’s Children from Other Relationship (Nonjoint Children)
a. Does Wife have minor child(ren) born prior to the marriage from another marriage

or relationship? YES NO

If YES, the full name, date of birth and age of each child born prior to the marriage

is:

Full Name of Date of Does Child Live Is Wife Court-Ordered to pay
Child and Age Birth with Wife? Child Support for this Child?
YES NO YES NO

YES NO YES NO

YES NO YES NO

YES NO YES NO

b. Has Wife given birth, since marrying Husband, to a minor child who is not a child of

the Husband? YES NO

If YES, answer (i) , (ii), (iii) and ( iv):

(i) List the full name, date of birth and age of each child born to Wife since marrying

Husband, who is not a child of the Husband:

Full Name of Child and Date of Does Child Is Wife Court-Ordered to
Age Birth Live with pay Child Support for this
Wife? Child?
YES NO YES NO

YES NO YES NO

(ii) Is there a Court Order naming someone other than the Husband as the father of

the child(ren) listed in (i) above? YES NO

If YES, submit a copy of the Order. The Order is for:
Full Name of Child(ren)

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(iii) Have the Wife and biological Father signed a Minnesota Recognition of

Parentage for any of the children listed in (i) above? YES NO

If YES, state the full name of the child: and

attach a copy of the Recognition of Parentage.

If NO, why not?

(iv) Has the Husband signed the “Husband’s Non-Paternity Statement ” for any of

the children listed at (i) above? YES NO

If YES, state the name of the child:

and submit a copy of the “Husband’s Non-Paternity Statement.”

If NO, why not?

16. Custody

It is in the child’s best interests and we agree that legal custody be granted as follows:
(check one)

□ Joint legal custody to both parents
□ Sole legal custody to □ Husband □ Wife

It is in the child’s best interests and we agree that physical custody be granted as follows:
(check one)

□ Joint physical custody to both parents
□ Sole physical custody to □ Husband □ Wife

17. Parenting Time

a. It is in the best interests of the children that:

Husband’s parenting time with the joint child(ren) be: (check one)

unsupervised supervised reserved

Wife’s parenting time with the joint child(ren) be: (check one)

unsupervised supervised reserved

If parenting time is unsupervised for both parents, skip to Question 18.

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b. supervised parenting time

(Option 1) Supervision is necessary because unsupervised parenting time is likely to

endanger the child’s physical or emotional health or impair the child’s emotional

development. The circumstances supporting this finding are:

(Option 2) We agree that supervised parenting time is necessary because

It is in the best interests of the child(ren) that supervision of parenting time be arranged

as follows: (State who should supervise parenting time, and if there is a cost involved,

who should pay the cost, and any other important details)

c. Reserved Parenting time

We agree that parenting time should be reserved because:

18. Public Assistance: (Note: If either person is receiving public assistance from the State of Minnesota or

applies for it after this proceeding is started, notice of this marriage dissolution action must be given to the

county’s collections and support office. See Minnesota Statutes Section 518A.44)

a. Husband receives public assistance from the State of Minnesota: Yes No

If YES, the assistance is from________________________County. (check all that apply)

MFIP in the amount of $ per month

Tribal TANF in the amount of $ per month

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General Assistance in the amount of $ per month

Medical Assistance

Child Care Assistance MinnesotaCare

b. Wife receives public assistance from the State of Minnesota: Yes No

If YES, the assistance is from _______________________County. (check all that apply)

MFIP in the amount of $ per month

Tribal TANF in the amount of $ per month

General Assistance in the amount of $ per month

Medical Assistance

Child Care Assistance MinnesotaCare

c. The joint children of the parties receive public assistance from the State of

Minnesota: Yes No

If YES, the assistance is from County. (Check all that apply):

MFIP Medical Assistance Tribal TANF MinnesotaCare

IV-E Foster Care

19. Supplemental Security Income (SSI)

Supplemental Security Income (SSI) is a Federal income supplement program. It is available to low-

income people if they are over age 65, or blind, or disabled.

a. Husband receives Supplemental Security Income (SSI): No Yes in the

amount of $ per month.

b. Wife receives Supplemental Security Income (SSI): No Yes in the amount

of $ per month.

c. The joint child(ren) of the parties receive(s) Supplemental Security Income (SSI):

No Yes in the amount of $ per month. What is the name of the

child receiving SSI?

20. Husband’s Employment

a. Husband is employed: Yes No Husband is self-employed: Yes No

b. Husband works at least 40 hours per week: Yes No

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If Husband is unemployed or working less than 40 hours / week, answer these

questions:

i. Why is Husband unemployed or working less than 40 hours / week?

ii. What is Husband’s past work experience (type of jobs, hours, pay, length of time at

the job) and what are Husband’s professional qualifications or licenses?

c. Current Employment: (if Husband currently has more than two jobs, use an attachment for the

additional jobs.)

Name of Husband’s Employer (If self-employed, list name and business address)

Employer’s Street Address

City State Zip Code

Name of Husband’s Employer if self-employed, list name and business address)

Employer’s Street Address

City State Zip Code

st nd
Questions about Current Jobs 1 Job 2 Job

Is Husband paid by the hour or hourly salary hourly salary
salaried?
What is the average number of
hours Husband works per week?
________________hours ________________hours

How much overtime pay does
Husband receive per week on
$_____________________ $____________________
average?

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Does Husband receive bonuses? If Yes, how much was received If Yes, how much was received
st in bonuses last year? in bonuses last year?
Yes No 1 Job
$_____________ $_____________
Yes No 2nd Job How much does Husband expect How much does Husband expect

to receive this year? to receive this year?
$___________ $___________

21. Husband’s Income

Source of Income Amount Per Month (or zero) before deductions/taxes

Self Employment Income $______________ per month

Self Employment income means gross receipts minus costs of goods sold

minus ordinary and necessary business expenses.

Job with __________________________ $______________ per month

Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Second Job with _____________________ $______________ per month

Third Job with ______________________ $______________ per month

Commissions from all jobs $______________ per month

Divide the total amount you expect this year by 12 to get a monthly average

Unemployment benefits $______________ per month

Social Security Retirement, Survivors or Disability

Income (RSDI) (do not include SSI) $______________ per month

Investment and Rental Income $______________ per month

Annuity payments $______________ per month

Pension or Disability from work or military $______________ per month

Worker’s Compensation $______________ per month

Court-ordered spousal maintenance received $______________ per month

Other income____________________________ $______________ per month
List Source

Add all of the above. Total monthly income $ ______________per month

Enter the amount of child support Husband is court-ordered
to pay for any nonjoint child(ren) $______________ per month

Enter the amount of spousal maintenance Husband is court-ordered
to pay to a current or former spouse $______________ per month

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Enter the amount of Social Security or Veteran’s Benefits received by a joint child
because of Husband’s retirement, disability, or other eligibility
$______________ per month
Which parent receives the payment for the child?
Husband Wife

22. Living Expenses for the Family

a. Husband and Wife and their child(ren) are still living together. Current monthly

living expenses for the family total $ .

OR

b. Husband and Wife are living separately. The monthly family living expenses

before separation totaled $ . At this time, Husband’s separate monthly

living expenses total $____________, and Wife’s monthly living expenses total

$______________. Of the total current monthly living expenses for Husband,

$_______________ amount is for expenses just for the child(ren) that live(s) with

Husband. Of the total current monthly living expenses for Wife, $___________is for

expenses just for the child(ren) that live(s) with Wife.

23. Expenses for Special Needs for the Children

a. Is there a joint child of the parties who has special needs and extraordinary medical

expenses? YES NO If Yes,

Name of child with special needs:

Describe the needs:

b. Does Husband’s monthly living expense (stated at #22) include the special needs

expenses for the child? YES NO

c. Does Wife’s monthly living expense (stated at #22) include the special needs expenses

for the child? YES NO

24. Wife’s Employment

a. Is Wife employed? YES NO Is Wife self-employed? YES NO

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b. Is Wife working at least 40 hours per week? YES NO

If Wife is unemployed or works less than 40 hours/week, answer these questions:

i. Explain why Wife is not working or why Wife works less than 40 hours/week

ii. What is Wife’s past work experience (type of jobs, hours, pay, length of time at the

job) and professional qualifications or licenses?

c. Current Employment: (If Wife has more than two jobs at this time, use an attachment for the

additional jobs.)

Name of Wife’s Employer (If Self-Employed list name and business address)

Employer’s Street Address

City State Zip Code

Name of Wife ’s Employer (If Self-Employed list name and business address)

Employer’s Street Address

City State Zip Code

st nd
Questions about Jobs 1 Job 2 Job

Is Wife paid by the hour or salaried? hourly salary hourly salary

What is the average number of ________________hours ________________hours
hours Wife works per week?

How much overtime pay does Wife
receive per week on average?
$_____________________ $____________________

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Does Wife receive bonuses? If Yes, how much did Wife If Yes, how much did Wife
st receive in bonuses last year? receive in bonuses last year?
Yes No 1 Job
$____________________ $___________________
Yes No 2nd Job How much does Wife expect How much does Wife expect to

to receive this year? receive this year?
$____________________ $___________________

25. Wife’s Income

Source of Income Amount Per Month (or zero) before deductions/taxes

Self Employment Income $______________ per month

Self Employment income means gross receipts minus costs of goods

sold minus ordinary and necessary business expenses.

Job with __________________________ $______________ per month

Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Second Job with _____________________ $______________ per month

Third Job with ______________________ $______________ per month

Commissions from all jobs $______________ per month

Divide the total amount you expect this year by 12 to get a monthly average

Unemployment benefits $______________ per month

Social Security Retirement, Survivors or Disability

Income (RSDI) (do not include SSI) $______________ per month

Investment and Rental Income $______________ per month

Annuity payments $______________ per month

Pension or Disability from work or military $______________ per month

Worker’s Compensation $______________ per month

Court-ordered spousal maintenance received $______________ per month

Other income____________________________ $______________ per month
Identify Source

Add all of the above. Total monthly income $ _____________ per month

Enter the amount of child support Wife is court-ordered
to pay for any nonjoint child(ren) $______________ per month

Enter the amount of spousal maintenance Wife is court-ordered
to pay to a current or former spouse $______________ per month

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Enter the amount of Social Security or Veteran’s Benefits received by a joint child
because of Wife’s retirement, disability, or other eligibility
$______________ per month
Which parent receives the payment for the child?
Husband Wife

26. Child Care Costs

Are there child care costs for joint children because of work or school? YES NO

If YES,

a. How many of the joint children need child care? One Two Three ________

b. How much does the daycare center(s) or babysitter charge per month? $

c. Does the County child support agency pay for child care through a subsidy or child care

assistance? Yes, child care assistance is being received. Husband’s Wife’s

co-pay for child care per month is $ .

No, there is no county child care assistance received .

d. The parties agree that Husband should pay $ per month for his

proportional share of child care costs and Wife should pay $ per

month for her proportional share of child care costs. These amounts are are not

based upon calculations using the child support guidelines worksheet.

27. Health Care Coverage

a. Who receives Minnesota Care or Medical Assistance?
Husband Wife Joint Children No one

b. Does Husband have medical insurance? (other than MN Care or Medical Assistance)
Yes No. If no, skip to c.

i. Where does Husband get the medical insurance?

through his employment

buys private medical insurance

ii. How much does the medical insurance cost?

$____________per month for single coverage

$____________per month for single plus spouse (if this is offered)

$____________per month for family coverage

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iii. Who is currently covered by this medical insurance?

Husband Wife All the joint children Some of the j oint children:

Name the joint children who are covered_____________________________________

Nonjoint children covered

c. Does Husband have dental insurance? (other than MN Care or Medical Assistance)

Yes No. If no, skip to d.

i. Where does Husband get the dental insurance?

through his employment

buys private dental insurance

ii. How much does the dental insurance cost?

$____________per month for single coverage

$____________per month for single plus spouse (if this is offered)

$____________per month for family coverage

Or, Dental is included in the medical insurance costs.

iii. Who is currently covered by this dental insurance?

Husband Wife All the j oint children Some of the j oint children:

Name the joint children who are covered____________________________________

Nonjoint children

d. Does Wife have medical insurance? (other than MN Care or Medical Assistance)

Yes No If No, skip to e.

i. Where does Wife get the medical insurance?

through her employment

buys private medical insurance

ii. How much does the medical insurance cost?

$____________per month for single coverage

$____________per month for single plus spouse (if this is offered)

$____________per month for family coverage

iii. Who is currently covered by this medical insurance?

Husband Wife All the j oint children Some of the j oint children:

Name the joint children who are covered____________________________________

Nonjoint children

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e. Does Wife have dental insurance? (other than MN Care or Medical Assistance)

Yes No If No, skip to f.

i. Where does Wife get the dental insurance?

through her employment

buys private dental insurance

ii. How much does the dental insurance cost?

$____________per month for single coverage

$____________per month for single plus spouse (if this is offered)

$____________per month for family coverage

Or, Dental is included in the medical insurance costs.

iii. Who is currently covered by this dental insurance?

Husband Wife All the joint children Some of the j oint children:

Name the joint children who are covered_____________________________________

Nonjoint children

f. If the joint children are without health care coverage, is coverage available for

purchase through Husband’s or Wife’s employer? YES NO The joint

children currently have health coverage.

g. Other:

28. Basic Support: Basic support is for a child’s housing, food, clothing, transportation,

education costs, and other expenses related to the child’s care.

Husband Wife shall pay basic support to the other party in the amount of

$ per month by the first day of the month, starting the first month

after entry of the judgment for divorce. Payment shall be through income withholding.

This amount is based on the calculations from the child support guidelines worksheet,

which is attached and incorporated into this Joint Petition.

Husband Wife shall pay basic support to the other party in the amount of

$ per month by the first day of the month, starting the first month

after entry of the judgment for divorce. Payment shall be through income withholding.

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This amount is a deviation from guidelines. The parties agree that this amount

adequately meets the needs of the child(ren) and is in the best interests of the child(ren).

29. Spousal Maintenance

Spousal Maintenance is money paid by one spouse to the other for living expenses.

Check only one box:

Husband and Wife do not need spousal maintenance at this time, or in the future.

Both parties agree that each party is fully capable of self-support and is not dependent

upon the other for additional support in the form of spousal maintenance. Each party has

made a full and fair disclosure of all income and assets and liabilities that each is

responsible for, and agrees that this waiver is reasonable. The waiver is fair and

equitable and is supported by the above consideration and was signed by both parties

after full financial disclosure to each other.

Husband or Wife may need spousal maintenance in the future. The court should

reserve maintenance to allow either party to ask for spousal maintenance in the future

because: (explain why you want to do this)

Husband needs spousal maintenance from Wife now. Husband is _________ years of

age, Husband and Wife have been married for _________ years. Husband has the

following education:________________________ . Husband’s gross

monthly income totals $__________________. Husband’s monthly expenses total

$______________ and Husband is not able to maintain the standard of living established

during the marriage because:

Wife has the ability to pay Husband $_____________per month for spousal maintenance.

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Wife needs spousal maintenance from Husband now. Wife is _______years of age,

Husband and Wife have been married for _______years. Wife has the following

education:______________________________________. Wife ’s gross monthly income

totals $______________. Wife ’s monthly expenses total $________________, and Wife

is not able to maintain the standard of living established during the marriage because:

Husband has the ability to pay Wife $_____________per month for spousal maintenance.

30. Name Change

a. Neither person wants to change his/her name.

b. Wife Husband wants to change his/her name to: (full name, not initials )

first middle last

This name change request is made with no intent to defraud or mislead anyone:

True False.

The person requesting the name change has been convicted of a felony

YES NO.

If YES:

i. Notice of this request for name change has been given to the proper authority as

required by Minn.Stat.§259.13. (IMPORTANT NOTICE: If you are a convicted

felon and you request a name change without following the requirements of Minn.

Stat § 259.13, using the new last name after your divorce is a gross misdemeanor.)

ii. An Affidavit of Service of the Notice marked Exhibit “A” has been submitted along

with this Joint Petition.

31. Other Findings

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AGREEMENT OF HUSBAND AND WIFE

1. We have made this agreement to settle once and for all what we owe to each other and

what we can expect to receive from each other. Each of us states that nothing has been

held back, and that we have honestly included everything we could think of in listing our

assets (everything we own and that is owed to us) and our debts (everything we owe) and

that we believe the other has been open and honest in writing this agreement. We will

sign and exchange any papers that might be needed to complete this agreement before or

after the divorce.

2. Legal Custody means which parent(s) have a say in the major decisions regarding the joint child(ren)’s life
including education, religious upbringing and medical treatment.

It is in the best interests of the child(ren) to grant legal custody of each minor joint child

of the parties as follows:

Name of Child Granting Legal Custody:

Solely to Husband OR Solely to Wife OR Jointly to
both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.

3. Physical custody identifies which parent(s) will handle the routine daily care and control of the joint

child(ren).

It is in the best interests of the child(ren) to grant physical custody of each of the minor

joint child (ren) of the parties as follows:

Name of Child Granting Physical Custody:

Solely to Husband OR Solely to Wife OR Jointly to
both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.

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Solely to Husband OR Solely to Wife OR Jointly
to both parties.
Solely to Husband OR Solely to Wife OR Jointly
to both parties.

4. Parenting Time

a. Husband’s parenting time shall be: Unsupervised Supervised Reserved

b. Wife’s parenting time shall be: Unsupervised Supervised Reserved

c. Parenting Time shall be scheduled as follows:

(Clearly explain the time each parent will spend with each child. Include the time
(o’clock) when the child will transfer from one parent to the other. If you want the order
to say who will pick up and drop off the child, include that under “Other.”)

Regular schedule:

Monday through Friday:

Weekends:

Summer (if you want a different schedule in summer)

Telephone contact with the child(ren): Unlimited or Only at certain times as

follows: (describe the days and times when the parent and child(ren) may have telephone

contact)

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Exceptions to the Regular Schedule:

You can have a different schedule for holidays, school release days, and birthdays. If you
do not want a different schedule, leave it blank.

School Release days or breaks during the school year

Any school release day schedule will supercede the regular parenting schedule.

Birthdays (child’s birthday, parent’s birthday)

Holidays

Any holiday or birthday schedule will supercede the regular and school release parenting

schedule.

Other

d. Under the above Schedule:
The children are with Husband: The children are with Wife:
less than 10% of the time less than 10% of the time
10-45% of the time 10-45% of the time
45.1-50% of the time 45.1-50% of the time
more than 50% of the time more than 50% of the time

5. Basic Support for the Joint Child(ren)

(Fill in a or b)

a. Husband Wife shall pay to Husband Wife $___________ per

month starting on (date):___________________as the basic support obligation for the

parties’ joint child(ren). This amount is based on the calculations from the child support

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guidelines worksheet, which is attached and incorporated into this Joint Petition. Any

past due amounts pursuant to a different court order of child support are still owed.

This amount is a deviation from the basic support obligation under Minnesota

laws, and the facts supporting the deviation from the basic amount are:

The monthly amount shall be:

subject to income withholding from the payor’s income, regardless of source, by

his by his or her employer, trustee, or other payor of funds and mailed to: Minnesota

Child Support Payment Center, P.O. Box 64326, St. Paul, MN 55164-0326. If the

person paying child support is self-employed, send payments to Minnesota Child

Support Payment Center, P.O. Box 64306, St. Paul, MN 55164-0306. To start

income withholding, Husband or Wife must apply for IV-D services or income

withholding-only services at the Child Support office in the County where the

children live. Until income withholding starts, the person owing support shall pay the

other parent directly.

OR

be paid directly by the parent owing the child support to the parent receiving the

child support, payable on the _________day of each month.

b. Child Support shall be reserved because:

Either party can ask the court to order the payment of child support in the future by

filing a Motion stating that there is a change in circumstances.

6. Medical and Dental Insurance for the Joint Children

Ordering Medical insurance as follows:

a. Husband Wife shall provide medical insurance for the joint child(ren)

through his/her employer or union. The other parent must pay a pro rata share of the

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health coverage costs by paying $_________________________ OR pay

nothing toward the medical insurance costs because he/she is financially unable to

contribute to the costs.

OR

b. Husband Wife shall provide medical insurance for the joint child(ren) by

obtaining and paying for private insurance. The other parent must pay a pro rata

share of the health coverage costs by paying

OR pay

nothing toward the medical insurance costs because he/she is financially unable to

contribute to the costs.

OR

c. Husband Wife shall pay $ per month as reimbursement

for Medical Assistance or Minnesota Care, payable by income withholding through

the Minnesota Child Support Payment Center, provided Medical Assistance or

Minnesota Care is open for the joint child(ren).

OR

d. Reserving the issue of medical insurance for the joint child(ren).

Ordering Dental Insurance as follows:

a. Husband Wife shall provide dental insurance for the joint child(ren)

through his/her employer or union. The other parent must pay a pro rata share of the

dental coverage costs by paying

OR pay

nothing toward the dental insurance costs because he/she is financially unable to

contribute to the costs.

OR

b. Husband Wife shall provide dental insurance for the j oint child(ren) by

obtaining and paying for private insurance. The other parent must pay a pro rata

share of the dental coverage costs by paying

OR

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pay nothing toward the dental insurance costs because he/she is financially unable

to contribute to the costs.

OR

c. Reserving the issue of dental insurance.

Other:

7. Uninsured and Unreimbursed Medical and Dental Expenses for the Joint Children

a. Husband shall pay _________ % of the uninsured and/or unreimbursed medical

and dental costs for the joint child(ren) of the parties, and Wife shall pay________%

based on the percentage share of combined PICS (parental income for determining

child support.)

The parent who paid the bill must tell the other parent to pay his/her percentage share. To

ask for payment, send to the other parent a) a copy of the bill, b) evidence that you have

paid the bill, and c) a letter requesting payment to you of your percentage share. This

request for payment should be made promptly, and no later than 3 months after the bill is

paid. If a request for payment is made after 3 months, there must be exceptional

circumstances to support the late request for payment.

The person receiving the request for payment shall make the payment within 30 days. If

there is a good reason to question the payment, send a letter to the other parent stating

what additional information is needed, or why payment is disputed. If neither payment

nor a written letter disputing payment is sent within 30 days of receiving the request for

payment, then the unpaid bill can be considered back due child support.

OR

b. Reserving the issue of uninsured and unreimbursed medical and dental costs.

“Uninsured and unreimbursed medical and dental costs” are expenses not covered by

insurance and not paid by medical assistance or MinnesotaCare. Examples include

deductibles, co-pays, and procedures not covered by insurance or assistance. Usually the

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parent with physical custody of the child will receive and pay the bill for the

unreimbursed costs.

8. Medical and Dental Insurance for the Parties

a. Each party shall provide for his or her own medical dental insurance.

b. ____________________________(full name) shall provide medical

dental insurance for ______________________________________________

(full name).

c. Allowing____________________________(full name), at his/her own expense,

to continue the dependent coverage available under the other party’s insurance

plan, pursuant to federal and state statutes.

d. Reserving the issue of medical and dental insurance for the parties.

9. Child Care Support

a. Husband shall pay $ per month for child care expenses,

and Wife shall pay $ per month for child care expenses; OR

b. Reserving the issue of child care expenses.

10. Spousal Maintenance

a. Neither party is awarded spousal maintenance. Petitioner and Respondent have

waived any claims to spousal maintenance for the past, present, or future, and

expressly waive all rights to modify their waivers of maintenance. This court is

divested of jurisdiction to award or modify maintenance in the future pursuant to

Karon v. Karon, 435 N.W. 2d 501 (Minn. 1989).

Consideration for this agreement is: (check all that apply)

the parties’ mutual waivers of maintenance

the property settlement

the parties’ respective incomes and ability to earn income

other:

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The Court has reviewed this agreement and finds it to be fair and equitable under all of

the circumstances, and supported by sufficient consideration including the parties’ mutual

waivers, incomes per year and the property division. Full disclosure of each party’s

financial circumstances has occurred.

b. Maintenance is reserved because:

Either party can ask the court to order the payment of spousal maintenance in the

future by filing a Motion stating a change in circumstances.

c. Husband Wife shall pay permanent spousal maintenance to the other party

in the amount of $ per month starting on (date):

d. Husband Wife shall pay temporary spousal maintenance to the other party

in the amount of $ per month starting on (date):

and ending on (date): .

The monthly amount of permanent or temporary spousal maintenance shall be:

subject to income withholding from the payor’s income, regardless of source, by his

or her employer, trustee, or other payor of funds and mailed to: Minnesota Child Support

Payment Center, P.O. Box 64326, St. Paul, MN 55164-0326. If the person paying

spousal support is self-employed, send payments to Minnesota Child Support Payment

Center, P.O. Box 64306, St. Paul, MN 55164-0306. To start income withholding,

Husband or Wife must apply for income withholding only services at the Child

Support office in their County and must send a copy of this Order to the Child

Support office. Until income withholding starts, the person owing maintenance shall

pay the amount directly to the spouse receiving it.

OR

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maintenance shall be paid directly by the spouse owing the maintenance to the spouse

receiving it, payable on the _____________day of each month.

11. Real Estate

Real estate includes a homestead, condominium, apartment building, vacant land,
contract for deed interest, remainder interest, and more.

Husband owns no real estate by himself or with anyone else.

Wife owns no real estate by herself or with anyone else.

Husband and/or Wife own real estate as described on the Real Estate Attachment(s).

(Use a separate Real Estate Attachment sheet for each parcel of real estate. The Real

Estate Attachment sheet(s) must be attached to this Joint Petition, even if Husband and

Wife have no real estate.)

All Real Estate Attachments are incorporated into this Joint Petition, Agreement,

Judgment and Decree and Husband and Wife agree that the real estate shall be awarded

as stated on the Real Estate Attachment(s) in Attachment “C”.

Check one:

There is one Real Estate Attachment; OR

There are ______ Real Estate Attachments.

12. Non-Marital Property

Non-marital Property means: (1) anything that you or your spouse owned before the marriage; (2)

a gift, bequest, devise, or inheritance made by a third party to one but not to the other spouse; (3)

anything that you or your spouse got in trade or in exchange for your non-marital property; (4)

anything that is an increase in the value of non-marital property (STOP: Property can be part non-

marital and part marital. Defining and valuing non-marital property can be complicated. If you

have any concerns or questions, you should stop here and talk to an attorney.) (5) anything you or

your spouse received after the valuation date set by the Court; or (6) anything defined as non-

marital property by a valid antenuptial contract.

a. Husband owns non-marital property:

YES NO

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If YES, Husband and Wife agree that that the following property is Husband’s non-

marital property and shall be awarded to Husband:

The total value of Husband’s non-marital property is $

b. Wife owns non-marital property:

YES NO

If YES, Husband and Wife agree that the following property is Wife’s non-marital

property and shall be awarded to Wife:

The total value of Wife’s non-marital property is $

13. Division of Marital Property

Marital Property means almost anything that you or your spouse own that you or your spouse

received during the marriage, even during the times that you and your spouse were separated.

This includes real estate, boats, cabins, household goods, furniture, jewelry, and other things.

(See attached Asset Sheet listing all assets. The Asset Sheet must be attached to the Joint

Petition, even if husband and wife have no assets.)

The Asset Sheet is incorporated into this Joint Petition, Agreement, Judgment and Decree

and Husband and Wife agree to divide their marital property as listed by them in Attachment

“A”.

14. Division of Marital Debts

Marital Debts means debts incurred by you or your spouse during the marriage, even during the

times that you and your spouse were separated. Do not include monthly expenses you pay in full

each month, such as telephone and utilities.

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(See attached Debt Sheet listing all debts. The Debt Sheet must be attached to the Joint

Petition, even if wife and husband have no debts.)

The Debt Sheet is incorporated into this Joint Petition, Agreement, Judgment and Decree

and Husband and Wife agree to divide their marital debts as listed by them in Attachment “B”.

15. Name Change

Neither party is requesting a name change.

Changing Husband ’s name to:
First Middle Last

Changing Wife’s name to:
First Middle Last

16. Paternity Question

Check only if applicable:

The Husband does not have a parent-child relationship with a child or children

named:

born to Wife during the marriage, and Husband is not the father.

The issue of paternity of the unborn child of Wife is reserved.

17. Other:

BASED UPON THE ABOVE INFORMATION, Husband and Wife request that the

Court issue a final judgment and decree terminating our marriage and ordering the terms of this

Agreement.

READ and SIGN the Verification and Acknowledgments.

STATE OF MINNESOTA )
) SS
COUNTY OF )
(County where documents signed)

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Verification and Acknowledgments

a. I have read this document. To the best of my knowledge, information and belief the
information contained in this document is well grounded in fact and is warranted by
existing law.

b. I have not been determined by any Court in Minnesota or in any other State to be a
frivolous litigant and I am not the subject of an Order precluding me from serving or
filing this document.

c. I am not serving or filing this document for any improper purpose, such as to harass the
other party or to cause delay or needless increase in the cost of litigation or to commit a
fraud on the Court.

d. I understand that if I am not telling the truth or if I am misleading the Court or if I am
serving or filing this document for an improper purpose, the Court can order me to pay
money to the other party, including the reasonable expenses incurred by the other party
because of the cost of serving or filing this document, Court costs, and reasonable
attorney’s fees.

e. WAIVER (Rule 306.01(c)): I know I have the right to be represented by a lawyer of my
choice. I hereby expressly waive that right and I freely and voluntarily sign this Joint
Petition and Agreement.

DATE: DATE:

Signature of Husband Signature of Wife
(Sign only in presence of notary public) (Sign only in presence of notary public)

( ) ( )
Daytime Telephone Number of Husband Daytime Telephone Number of Wife

Sworn / affirmed to before me this Sworn / affirmed to before me this

Day of , Day of , _____

______________________________
Notary Public Notary Public

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HUSBAND’S ATTORNEY WIFE’S ATTORNEY

Husband is Wife is

acting as his own attorney acting as her own attorney

OR OR

is represented by the following attorney: is represented by the following attorney:

Name Name

Address Address

City / State / Zip City / State / Zip

Telephone Telephone

Attorney Registration Number Attorney Registration Number

(If public assistance is being provided to a party or joint child(ren), the public authority must

sign off on this Joint Petition and Agreement.)

The public authority responsible for the collection and enforcement of child support reviewed

and agreed to the Joint Petition and Agreement of the above-named parties.

DATE:

Name and Title

Attorney Registration No.

Address

City / State / Zip

Telephone

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COURT ORDER

This case came before the Court without a hearing on the parties’ Joint Petition for

Dissolution of Marriage because both parties are represented by attorneys . The Court, having

reviewed the file, makes the following Order:

OR

This proceeding for dissolution of marriage came before the undersigned judge of district

court on (date) at (location) in

the State of Minnesota. Husband did did not appear. Wife did did not appear.

appeared as attorney for

Husband is NOT represented by an attorney OR

Husband is represented by the following attorney:

Wife is NOT represented by an attorney OR

Wife is represented by the following attorney:

1. The parties’ Joint Petition and Attachments contains the necessary facts and includes an

agreement on all issues before the Court. The real estate, if any, and the personal property

of the parties is hereby awarded according to the division set out in their foregoing Joint

Petition, which is made part of this final judgment. Debts and liabilities of the parties

must be paid as provided in their foregoing Joint Petition. Spousal maintenance, custody,

parenting time, and child support are ordered as set out in the Joint Petition and

Agreement. The parties are ordered to obey all of its provisions.

2. The marriage between the parties is dissolved and the parties are single.

3. Husband’s Wife’s name is changed to:

first middle las t

4. Each party shall execute any documents necessary to transfer real estate and personal

property as awarded herein without further order of the Court. Should either party fail to

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execute the necessary documents, a certified copy of the Judgment and Decree shall

operate to transfer title as awarded herein.

5. NOTICE: IF THE AGREEMENT OF THE PARTIES INCLUDES AN AWARD OF
SPOUSAL MAINTENANCE AND / OR CHILD SUPPORT, Appendix A is
incorporated and made a part of this final judgment. Appendix A contains, among other
things, provisions regarding payments to the Public Agency pursuant to Minnesota
Statutes § 518A.50; Depriving Another of Custodial or Parental Rights – A Felony,
Minnesota Statutes § 609.26; Rules of Support, Maintenance, Parenting Time; Parental
Rights from Minnesota Statutes § 518.17, subdivision 3; Wage and Income Deduction of
Maintenance and Child Support pursuant to Minnesota Statutes § 518A.53; Change of
Address or Residence; Cost of Living Increase of Maintenance and Child Support
pursuant to Minnesota Statutes § 518A.75; Judgments for Unpaid Maintenance and Child
Support pursuant to Minnesota Statutes § 548.091; Medical Insurance and Expenses
pursuant to Minnesota Statutes § 518A.41; and Minnesota Statutes § 259.115 regarding
criminal penalties for failure to comply with felon name change law.

General Rule of Practice 125 notwithstanding, let Judgment be entered immediately.

The foregoing facts were found BY THE COURT
by me after due hearing and the
Order thereon is recommended.

District Court Referee Judge of District Court

Dated: Dated:

Judgment

I certify the above constitutes the Judgment of the Court and Judgment is hereby entered.

Court Administrator

Deputy

Dated:

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Attachment “A”
DIVISION OF ASSETS AND VALUE

Husband’s Name:

Wife’s Name:

1. We agree on how to divide our assets (everything we own and that is owed to us).
2. Each person shall receive as their own all assets in their column.

Definitions: Current Fair Market Value is an estimate of the amount of money you could get
if you sold the item to a stranger, such as through a newspaper advertisement. It does not mean
what you paid for it originally, and it does not mean what it would cost you to replace it if you
lost it. If you are still paying for an item, list it in husband’s or wife’s column at the present
value.
Present value means the current fair market value minus the amount you still owe.

Who Gets the Item and What is the Value
*Enter the current fair market
value or present value of the item in
DESCRIPTION OF ASSETS the column of the person getting the
item.
 If you do not have the type of property described, enter a zero
in the columns for Husband and Wife.

 To avoid confusion at a later date, describe each item as clearly
as possible. For example, include the last 4 digits of account *HUSBAND *WIFE
numbers (xxx2873), names of banks, & whose name is on the
title or account, if applicable.

 List all property owned separately or together, no matter when
it was acquired, except do not list the non-marital property
described at #12 of the Joint Petition.
Cash on hand: $ $

Cash in banks/credit unions: (Name of bank, last 4 digits of
account number, whose name is on the account)
$ $
$ $
$ $
$ $
$ $
Stocks/Bonds:
$ $
$ $
$ $
$ $
$ $

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Notes (money owed to you in writing):
$ $
$ $

Husband Wife
Money owed to you (not evidenced by a note):
$ $
$ $
$ $
Business interests: (Name of business, who owns it)
$ $
$ $
Automobiles: (Year, Make, Model) (Reminder: Use present
value if you are still paying for the items.)
$ $
$ $
$ $
$ $
Boats:
$ $
$ $
Other vehicles: (Snowmobiles, 4-Wheelers, etc.)
$ $
$ $
$ $
Retirement plans
Profit Sharing or Pension: (Enter “present value”. Contact plan
administrator for the present value. Include name of employer/group providing
the plan, and type of plan.)
$ $
$ $
401(k), IRAs or other: (Enter current account balance, name of bank
where funds are held, whose name is on the account.)
$ $
$ $
$ $
Furniture & furnishings:
We have already divided the furniture and furnishings in a fair $ $
manner. (Enter in each spouses’ column the total value of their share of
the furniture and furnishings already divided);
We agree to divide the furniture and furnishings as follows: (List
items not included above.)
$ $
$ $
$ $
$ $

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$ $
$ $
$ $
$ $

Husband Wife
Collectibles & Jewelry:
$ $
$ $
$ $
$ $
Life insurance: (cash surrender value) (Name of insurance company and
last 4 digits of policy number.)
$ $
$ $
Sporting & entertainment & electronic equipment: (TV,
stereo, guns, etc.)
$ $
$ $
$ $
$ $
$ $
$ $
Real Estate:
Do Not List Here. Use Real Estate Attachment.

Other assets:
$ $
$ $
$ $
$ $
Total Value of Property To Each Person: Husband Wife
(Excluding Real Estate, and any Non-Marital Property listed at
Paragraph # 12 of the Joint Petition.) $ $

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Attachment “B”
DIVISION OF LIABILITIES/DEBTS

Husband’s Name:

Wife’s Name:

Date we filled out this form:
1. We agree on how to divide our marital debts (debts we have incurred since our marriage date,
either separately or together).
2. Each person shall pay as their own the debts listed in their column, and shall not ask the other
person to pay these debts/bills.
3. We have listed all marital debts we know of on this Attachment. Any debts incurred by one of
us alone and not listed on this Attachment shall be paid by the person whose name is on the
debt/bill.
*Write the current amount
DESCRIPTION OF DEBT(S) owed in the column of the
 If you do not have the type of debt described, enter a zero in the person who will pay it.
columns for Husband and Wife.

 To avoid confusion at a later date, describe each debt as clearly *HUSBAND *WIFE
as possible. For example, state who the debt is owed to, whether
husband’s or wife’s name is on the debt, and the last 4 digits of
account numbers (xxx3094), if applicable.

 List all debts in husband’s name alone and in wife’s name alone
and in both names together. Include debts incurred during the
marriage and after separation. Do not include bills you pay in
full each month.

Mortgages and loans on Real Estate:
Do not list here. Use the Real Estate Attachment.
Charge/credit card accounts:
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Auto loans:
$ $
$ $
$ $

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Bank/credit union loans:
$ $
$ $
$ $
$ $
Husband Wife
$ $
$ $
Student loans:
$ $
$ $
$ $
$ $
Money you owe: (not evidenced by a note )
$ $
$ $
$ $
$ $
Judgments:
$ $
$ $
$ $
Other debts:
$ $
$ $
$ $
$ $
$ $
Husband Wife
Total Debts to be Paid by Each Person:
(Excluding Real Estate mortgages and loans.) $ $

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Attachment “C”
REAL ESTATE ATTACHMENT

Fill out a separate Attachment for each parcel of real estate.

1. Real Estate belongs to: (List all owners)

2. Street Address of the real estate is:

City State Zip Code

The property is in County.

3. Legal Description is: (Use the full legal description from the deed. If the legal

description is long, you may use an attachment. Type or print neatly.)

4. Purchase date (month, day, year) and purchase

price: $ .

5. Mortgages or loans: (Write “NONE” if there is no mortgage).

st
1 Mortgage: Amount currently owed $ and name of lender

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2nd Mortgage: Amount currently owed $ and name of lender

6. Current Market Value of this property: $

7. This property is the homestead: Yes No

AGREEMENT OF HUSBAND AND WIFE

1. All right, title, and interest of Husband and Wife in the real estate described above shall

be awarded to:

Husband Wife

2. Husband and Wife also agree that: (Describe any liens in favor of husband or wife, or

other agreements about the use, sale of, or award of the property. Attach additional pages

if needed. If there are no other agreements, write “None”.)

3. The Mortgage(s) or Loan(s) described above shall be paid by Husband Wife

starting on the following date:

(write “NONE” if there is no mortgage or loan.)

DIV1702 State ENG Rev 7/ 11 www.mncourts.gov/forms Page 41 of 41

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