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.
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_________________________________
Date
Judge
Distribution:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Type or Print Name
Type or Print Name
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Street Address
Street Address
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
City, State and Zip Code
City, State and Zip Code
Form #PS-31152-3
Approved by State Court Administration 02/10