Decree of Dissolution of Marriage

This form must be fulfilled and signed upon the divorcing spouses’ arrival at an agreement regarding the division of their conjugal assets and debts.Download

Extracted Text for Proper Search

Form #PS-3115	2-3 	
Approved b	y State Cour	t Administration	 02/10	 
 	
 ) 	SS: 	 	
 
IN RE THE MARRIAGE OF:  
 
 
Petitioner,  
 
V. 
 
 
Respondent.  
 	
DECREE OF 	DISSOLUTION	 O	F MARRIAGE AND S	ETT	LEME	NT AGRE	EMENT	 	
 
The parties having sub	mitted their Settlem	ent Agreem	en	t and the cou	rt having s	ee	n and consid	ered th	e 	
Verif	ied Petition f	or Dis	solution of	 Marr	iage an	d Verif	ied W	aiver of	 Final Hear	ing subm	itted by the 	
parties, now approves th	e following agreem	ent:  	
 
1. 	The parties were m	arried 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 m	onths prior to the filing of th	e Verified Petitio	n for 	Dissolution of Marriage. 	
 
3. 	____________________________________________________________ is not pregnant. 	
 
4. 	Neither p	arty is a m	ember of	 the m	ilita	ry.	 	
 
5. 	There were children born of this m	arriage; nam	ely; 	
 	
Name	 	Date of birth	 	
______________________________ _________________ 
______________________________ _________________ 
______________________________ _________________ 
______________________________ _________________ 	
 
6. 	The parties agree and state th	at it is in 	the be	st interes	t of	 th	e 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 phys	ical custody and the parties sh	all have joint legal custody 	
of the child	(ren)  	
 	
STATE OF INDIANA 	) 	IN THE ___________________	 SUPERIOR/CIRCUIT COURT 	
COUNTY OF _______________	     )  CASE NO.  ________________	 	  	
______________________  
______________________

Form #PS-3115	2-3 	
Approved b	y State Cour	t Administration	 02/10	 
 	
Respondent shall have sole phys	ical custody and the parties sh	all have joint legal custody 	
of the child	(ren).	 	
 
Other:  ___________________________________________________________ 	
 
7. 	The parties have agreed on the followi	ng Parenting Tim	e (Vi	sitation) order: 	
 	
Petitioner shall have reasonable 	visita	tion with the	 m	inor child	(re	n) as the parties agree or 	
accord	ing to	 the Ind	iana Parenting Tim	e guidelines. 	
 
Respondent shall have reasonable visitation with	 the m	inor child(ren) 	as the parties agree 	
or acco	rding	 to the Indiana Parenting	 Tim	e guidelines.  	
 
Other:  ___________________________________________________________ 	
 
8. 	____________________________________________________________ will pay ch	ild support 	
in the am	ount of _______________ per week, as shown by 	the attached child support worksheet, 	
through the County Clerk’s office, or by incom	e w	ithholding order if available from	 the em	ployer, 	
beginning on the first Friday following the da	te of the decree.  Said date is _________________.  	
____________________________________________________________ will be resp	onsible for the 	
first __________________ of uninsured m	edical	 expenses for the m	inor child(ren).  T	hereafter, Father 	
shall be responsible for _______% of uninsured m	edical	 expenses, and Mother shall be responsible for 	
_______% of uninsured m	edical expe	nses for the m	inor child(ren). 	
 
9. 	The parties have agreed on th	e following provisions for heal	th insurance m	aintenance: 	
 	
____________________________________________________________ shall m	aintain 	
medical, dental, and optical insurance as ava	ilable through employm	ent on the m	inor child(ren): 	
10.	 	The parties have agreed on the 	following arrangem	ent for claim	ing the tax credits, exem	ptions, 	
and deductions for the m	inor child(ren): 	
 	
Petitioner sh	all be entitle	d to	 claim	 the m	inor child(ren) for federal, state, and local 	
incom	e tax purposes on an annual basis; Res	pondent shall sign all necessary docum	ents 	
that will en	title Pe	titione	r to do so.  	
 
Respondent shall be entitled to claim	 the m	inor child(ren) for f	ederal, state, and local 	
incom	e tax purposes on an annual basis; Pe	titioner shall sign all necessary docum	ents 	
that will entitle Respondent to do so. 
 
Petitioner an	d Respondent shall each	 be entitled 	to claim	 the m	inor child(ren) for federal, 	
state, and lo	cal in	com	e tax purposes in altern	atin	g years;  Pe	tition	er sha	ll be entitled to 	
claim	 the m	inor child(ren) in the ye	ar ________, and every _______ year thereafter; 	
Respondent shall be entitled to claim	 th	e m	inor child(ren) in the year ________, and 	
every _______ year thereafter.  
 
Other:  ___________________________________________________________ 	
______________________________________________________________________________	 	
______________________________________________________________________________

Form #PS-3115	2-3 	
Approved b	y State Cour	t Administration	 02/10	 
 	
 
11.	 	The parties have agreed on th	e following debt division:  	
 	
The parties already have 	divided their debts.  	
 
Petitioner w	ill b	e solely responsib	le for 	and shall hold Respondent harm	less from	, the 	
following debts: 	
 	
Name of Creditor	 	Amount of Debt	 	
______________________________ __________________ 
______________________________ __________________ 
______________________________ __________________ 	
 	
Respondent will be so	lely responsib	le for, and shall ho	ld Petitioner harm	less from	 the 	
following debts: 	
 	
Name of Creditor	 	Amount of Debt	 	
______________________________ __________________ 
______________________________ __________________ 
______________________________ __________________ 	
12.	 	The parties have agreed on th	e following vehicle division: 	
 	
There are no vehicles to divide.  
 
Petitioner w	ill h	ave sole possession o	f th	e following vehicles, and Respondent shall 	
execute all d	ocum	ents 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

Form #PS-3115	2-3 	
Approved b	y State Cour	t Administration	 02/10	 
 	
Respondent will have sole possess	ion	 of th	e following vehicles, and Petitioner shall 	
execute all d	ocum	ents 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 th	e following property division: 	
 	
The parties already have divi	ded all item	s of property.  	
 
Petitioner w	ill h	ave sole possession o	f the f	ollowing item	s of	 property	: 	
Respondent will  have so	le posses	sio	n of the following item	s of property: 	
14.	 	The m	arriage has suffered an irretrieva	ble breakdown and should be dissolved. 	
 
15.	 	Change of nam	es: 	
 	
W	ife would like her m	aiden nam	e or previous m	arried nam	e of 	
__________________________________________________________ restored to her.  
 
W	ife does not want to change her nam	e.  	
 	
The parties have disclosed all relevant docum	ents 	and exchanged all inform	ation on value of property, 	
pensions, real estate, and ot	her assets and debts. The parties agree 	that this division of	 property is/is not 	
an approxim	ate equal division of the 	assets and debts. The parties agr	ee that if this division is not a 	
nearly equal division, th	at the d	eviation from	 the	 presum	ptive equal d	ivision should b	e accep	ted b	y the 	
Court becau	se it is th	e p	arties’ agreem	ent and neither 	party h	as been forced or threatened to accep	t this 	
agreem	ent. 	
 
I affirm	 under the penalties of perjury th	at the foregoing repres	entations are true.	 	
 
 
____________________________  
Your Signature 
 
 	
______________________________________________________________________	___	 	
______________________________________________________________________	___	 	
______________________________________________________________________	___	 	
______________________________________________________________________	___

Form #PS-3115	2-3 	
Approved b	y State Cour	t Administration	 02/10	 
 	
STATE OF INDIANA  	) 	
    )	 	SS: 	
COUNTY OF ____________) 
 
Before m	e, ______________________________, a notary public in and for ________________ 	
County, State of Indiana, personall	y appeared ______________________________, and he/she being 	
first duly sw	orn upon his/her oath, says that the fact	s alleged in the foregoi	ng instrum	ent are true. 	
Date 	________________ 	   __________________________________ 	
       N	otary Public 	
MY COMM	ISSION EXPIRES: 	
_________________________ 
 
 
______________________________ 
Your Spouse’s Signature 
 
STATE OF INDIANA  	) 	
    )	 	SS: 	
COUNTY OF ____________) 
 
Before m	e, ______________________________, a notary public in and for ________________ county, 	
State of Indiana, personally appe	ared ______________________________, and he/she being first duly 	
sworn upon his/her oath, says that the facts al	leged in the foregoing instrum	ent are true. 	
Date 	________________ 	   __________________________________ 	
       N	otary Public 	
MY COMM	ISSION EXPIRES: 	
_________________________ 
 
 
IT IS THEREFORE ORDERED 	by the Cour	t tha	t the pa	rties	’ m	arriage is hereby dissolved, and the 	
term	s of	 their agre	em	ent as set ou	t ab	ove shall be incorpor	ated	 into th	is Or	der.	 	
 	
________________________________  	 	_________________________________ 	
Date 	 	      Judge 	
 
 
Distribu	tion	: 	
 
_____________________________________ 	_____________________________________ 	_____________________________________ 	_____________________________________ 	_____________________________________ 	_____________________________________ 	
Type or Print Name  	Type or Print Name  	
_____________________________________ _____________________________________ _____________________________________ 	_____________________________________ _____________________________________ _____________________________________ 	
Street Address 	Street Address 	
_____________________________________ _____________________________________ _____________________________________ 	_____________________________________ _____________________________________ _____________________________________ 	
City, State and Zip Code 	City, State and Zip Code