APPENDIX M SEPARATION AGREEMENT WORKSHEET FOR OFFICIAL USE ONLY - PRIVACY ACT SENSITIVE, Any misuse or unauthorized disclosure may result in both civil and criminal penalties. PRIVACY ACT STATEMENT: AUTHORITY § USC 301, Departmental Regulations; 10 USC 1044, SYSTEM OF RECORDS NOTICE: MJA00002. ROUTINE USE(S): Information provided is used to provide an administrative record for use by attorneys and clerical personnel directly involved in providing legal assistance, to manage internal counsel assignment, and for internal management of the office, to include generating periodic workload productivity and statistical reports. MANDATORYIVOLUNTARY DISCLOSURE CONSEQUENCES OF REFUSAL TO DISCLOSE: Disclosure of requested information is voluntary, but failure to provide such information may limit the Legal Assistance Office's ability to provide assistance, [This WORKSHEET information will be used by a legal assistance attorney to draft a Separation| |Agreement and/or Property Settlement and other Dissolution (Divorce) documents. If you have. [questions arising from the worksheet call the Legal Assistance Office at DSN 645 - 1037. Ifa question does not apply, please indicate N/A for "not applicable." IT IS VITAL THAT THIS WORKSHEET, BE COMPLETED ACCURATELY. Please type or print NEATLY. Use black ink and answer all sections. Any discrepancies will cause delays. THIS WORKSHEET IS NOT A BINDING| AGREEMENT BETWEEN SPOUSES EVEN IF IT IS SIGNED BY BOTH PARTIES. THE| JRESULTING SIGNED SEPARATION AGREEMENT WILL BE BINDING. Military Personnel: A Separation Agreement PREPARED BY A LEGAL ASSISTANCE OFFICE IS NOT A COURT ORDER and does not mean you are free to engage in extra-marital sexual relations. Be aware that Article 134, UCMJ, applies, Only a court can terminate your marriage, ‘TYPE OF SERVICES SOUGHT: CUSEPARATION [1 DISSOLUTION (DIVORCE) Who will file? OHUSBAND =O WIFE, CLIENT INFORMATION: CLIENT: O HUSBAND O WIFE DATE CLIENT EXPECTED TO LEAVE THIS AREA: Is the opposite party represented by legal counsel? D No OI do not know O Yes (Name/Firm: ) ILA ude de 24 Page 1 of 24 rpsPERSONAL INFORMATION A. HUSBAND, 1. Personal Information Full name aa First) (Middle) Cast) Telephone: Home Work DoD ID EDIPI Date of Birth (MM/DD/YYYY): Residence (where you are physically living now): (Number, Street, Apt) (Ci, State) (Zip Code) Residency began (MM/DD/YYYY): State of legal domicile (the place you consider your PERMANENT HOME) 2. Employment Active duty military? 1 Yes; rank: ONo a. Unit name: b. EAS: Total service time: Years Months Occupation: Work Address: (Unit, Business Name, etc.) NO ABBREVIATIONS (Number, Street, Apt) ‘Gity, State Zip Codey Gross monthly income: Estimated value of assets: ILA ype Jane 21 Page 2 of 24 ApexB. WIFE 1. Personal Information Full name: (First) (Middle) (Last) Maiden name: Telephone: Home Work DoD 1D EDIPI Date of Birth (MM/DD/YYYY): Residence (where you are physically living now): (Number, Street, Apt.) (City, State) (Zip Code) Residency began (MM/DD/YYYY): State of legal domicile (the place you consider your PERMANI 2. Employment Active duty military? 1 Yes; rank: OONo a. Unit name: b. EAS c. Total service time: Years Months Work Address: (Unit, Business Name, etc.) NO ABBREVIATIONS (Number, Street, Apt) ‘City, State) (Zip Codey Gross monthly income Estimated value of assets: JA wpa Je 21 Page 3 of 24 poxMARRIAGE & SEPARATION MARRIAGE: A. Date of marriage (MM/DD/YYYY): B, Place of marriage (City) (County) (State) C. Total time married: Years Months D. Ifyou have a prenuptial agreement, date when it was signed: (MM/DD/YYYY) BANKRUPTCY: Has either party previously filed for bankruptcy? O Yes C1No Af YES, explain when and where you filed and the type of bankruptcy: SEPARATIO! (States have different residency requirements and periods of separation required prior to filing - discuss this with your attorney) ‘A. This is the date the parties separated with the intent never to resume the marital relationship, This date has important implications regarding the accumulation of marital property and marital debt. Date of separation (MM/DDIYYYY): The date of separation is the date you PHYSICALLY began living apart with the intent to separate. (® Note ~Some states have “legal” separations via court order ~ specify jurisdiction/date) B. The address where you and your spouse last lived together as Husband and Wife Was the residence 1 owned by both of you Downed by the Husband Downed by the Wife D rented The residence will be the residence of O the HUSBAND 1 the WIFE C1 NEITHER JA upetd June 21 Page 4 of 24 AppxSPOUSAL SUPPORT Spousal support is an amount of money paid to one party for temporary support in his or her own right. It is not considered part of child support. NOTE: Due to changes in tax law. alimony will no longer be tax deductible. A. Maintenance Payments: 1 Waived by both parties (SKIP THIS SECTION). o {0 pay specific amounts to Amount to be paid per month: Date payment begins: (MM/DD/YYYY). Payments are due: 1 1* 0 15 0 30Q Other B. Termination of maintenance payments: 1D Support payments to terminate on remarriage of party receiving support or death of either party 1 Support to terminate upon remarriage of party receiving support or death of either party or on (date MM/DD/YYYY) whichever oceurs first 8 Other: C. Maintenance payment increases. Are maintenance payments to increase with an escalator clause? 1 Yes C1 No IFYES, maintenance payments are to increase with: [ Consumer Price Index (CPI) escalator 1 __Net or__ Gross pay escalator 1 Flat-rate escalator: INDICATE rate. ATTORNEY ONL’ Payments to be made by: 1 wage assignment money order © check 1 direct deposit D military allotment Does the amount of maintenance derive from the presumptive amount determined by the state’s maintenance guidelines? C1 Yes EI No If yes, should the agreement contain an explanation as to why it derives? 11 Yes (I No Explanation: Can the provision on maintenance be modified by a count? Dl Yes EI No J wpe Je 21 Page 5 of 24 AesCHILD CUSTODY, CHILD SUPPORT, CHILD VISITATION Are there children born and/or adopted of this marriage? (1 Yes No (IF “NO” SKIP TO NEXT SECTION) Complete this section for each natural child bom of the marriage and/or adopted during the marriage. CHILD'S FULL NAME oe op) | ASE crryisrarE MIF MF MF MF Is the wife currently pregnant? Yes; expected due date (YYYYMMDD): OONo CHILD CusTopy: You can choose between joint legal custody (one parent has primary physical custody, but both parents have an equal voice in major life decisions) or sole legal eustody (the "custodial parent” has full-time physical and legal custody of the children, and the "non-custodial parent" usually receives visitation rights). 1 Joint Legal Custody: One parent has primary physical custody, but both parents have an equal voice in ‘major life decisions. Please indicate below the type of custody arrangement both parties desire: Joint Legal with the children’s residence with the WIFE } Joint Legal with the children’s residence with the HUSBAND 1 Sole Custodv. The "custodial parent" has full-time physical and legal custody of the children. The "non- custodial parent” normally receives visitation rights. (__) Sole physical and legal custody to the WIFE (_) Sole physical and legal custody to the HUSBAND Should the separation agreement recite that upon the death of the custodial parent, the non-custodial parent shall have custody? O Yes [1 No ILA upd Jee 21 Page 6 of 24 Apps MeCHILD SUPPORT: Support payments, in most states, are controlled by State Child Support Standards or Guidelines. Support agreements below the minimum level may be invalidated by a court. A court may increase the obligation to the ‘minimum level based on the income/salaries of the parties. Child support is normally paid by the non-custodial spouse. Every military member is required to support his or her lawful family members. A support obligation established in a divorce or legal separation is legal, binding, and enforceable. Any amount agreed upon by the parties in a signed separation agreement will be binding during the period of separation. Each party should talk to an attorney about how much support should be paid during the separation period. A. Party to PAY child support: OHUSBAND OO WIFE 1 NEITHER B. Party to RECEIVE child support: O HUSBAND WIFE ONEITHER C. Monthly support per child: ‘The monthly child support to be paid by the non-custodial parent to the custodial parent each month for each chil 8 per month for EACH child D. Total monthly support for all children: The total monthly child support payment for all children: $ per month for ALL, children E. Schedule of child support pavments: Will begin on: (MM/DD/YYYY) Payments ere due: O11" O15" 0130 (1 Other: day of each month ATTORNEY ONLY: Payments to be made by: 1 wage assignment EI money order (1 check (1 direct deposit 1 military allotment Payments to be made : B Directly to the custodial parent CI Through a state Child Support Enforcement Office F, Termination of child support payments: [Normally child support obligations end when one of the following occurs: the child dies, the child reaches age 18 (or age 22 as long as the child enters and continues to attend college); the child Imatries; or the child is otherwise emancipated, WIFE and HUSBAND can agree whether to extend payments, for example, to cover college expenses. Support will terminate upon a child’s death, marriage, emancipation, or upon the attainment of the age of 18 years by the child. ILA ype Je 27 Page 7 of 24 Appx M1 Support will terminate upon a child's death, marriage, emancipation, or upon the attainment of the age of 18 years by the child or years, if the child enters and continues to attend college. 1 Support will terminate upon a child's death, marriage, emancipation, or upon the attainment of the age of years by the child, O Other: G. Child support payment increases. Are child support payments to increase with an escalator clause? [1 Yes CNo If YES, support payments are to increase with: © Consumer Price Index (CPI) escalator OO __Net or__ Gross pay escalator 1 Flat-rate escalator: INDICATE rate. H. Payments for college: Neither party will be responsible for payments for college Both HUSBAND and WIFE will share college expenses equally Child support obligor to pay all of the college expenses College expenses to include the following: [1 Books 1 Room and Board O Tuition OI Fees Length of obligation to pay college expenses: 1 Eight college semesters DAge: 22 (or) __ Age: 1 Four years Payment of college expenses (__) WILL (__) WILL NOT be conditioned on the child's full-time attendance at a college approved by the (__) PAYOR (__) BOTH HUSBAND AND WIFE. 1. Child care expenses: The total monthly child care expenses for each child is: S and the total per month for ALL, children is $ ‘The Husband shall pay $ per month toward to the total child care expenses and the Wife shall pay $ per month. ATTORNEY OND Does the amount of child support derive from the presumptive amount determined by the state’s child support guidelines? 1 Yes E1 No If yes, should the agreement contain an explanation? C1 Yes 1 No Explanation: Can the parties seek to modify child support in the future? O They explicitly ean I They explicitly cannot 1 The agreement is to be silent about modification ILA sped ane 21 Page 8 of 24 Appx MCHILD VISITATION: A. Visitation rights to be given to: HUSBAND O WIFE O Neither. Waived by B. Schedule of Visitation: 1 Reasonable visitation (no specific schedule of visitation) Additional conditions (optional): (SKIP ToC) OR C1 According to a specific schedule (SPECIFY BELOW) 1. Weekday visitation: O No O Yes; until what time?: Conditions: (Advance notice, site, etc.) 2, Weekend visitation: C1 No 1 Yes (choose below) © Every weekend (both Sat and Sun) Gi Every other weekend (both Sat and Sun) D Every weekend (either Sat or Sun) Every other weekend (either Sat or Sun) 1D Other: 1 One (1) weekend per month Weekend is from (time) _: on (day) until (time) ‘on (day) Conditions: (Advance notice, site, ete.) 3. Holiday Visitation: ENo 1 Yes; the non-custodial parent will have the following holiday visitation rights: D Christmas: even or odd years D Thanksgiving: even or odd years D Spring vacation: even or odd years 1 Other Holidays (identify Holiday and indicate period of time with each parent): . Summer Visitation: No O Yes If YES, number of: days weeks months Describe any other conditions (advance notice required, etc.) of summer visitation: ILA wpe Jee 21 Page 9 of 24 Appx MtC, ‘Transportation costs for tation: 1D WIFE will pay all transportation costs 1D HUSBAND will pay all transportation costs 1 Shared between HUSBAND and WIFE equally 1 Other Agreement. Specify: D. Grandparent Visitation: This may be included in the agreement, if necessary, to set visitation for the grandparents of the visiting parent's side of the family. 1D Agreement to include a provision on grandparent reasonable visitation rights 1 Agreement to be silent on visitation rights for grandparents 1 Other terms (Deseribe specific terms, ic., frequency): E. Moving the children's residence: 1 No restrictions Visitation rights shall be modified if residence is changed Moving from the State of, is proh tiles of current residence is prohibited. ILA upd Je 21 Page 10 of 24 ArpsMEDICAL COVERAGE AND INSURANCE MEDICAL COVERAGE FOR SPOUSE: Extend of coverage: CLHUSBAND will maintain coverage on WIFE until the divoree is final 1D Basic coverage (including dental? (_) yes ) no) 1 Major coverage (including dental?) yes () no) 1 WIFE will maintain coverage on HUSBAND until the divorce is final D Basic coverage (including dental? (_) yes } no) 1 Major coverage (including dental?) yes C) no) If HUSBAND leaves the military service, he will purchase independent medical coverage for WIFE Dif WIFE leaves the military service, she will purchase independent medical coverage for HUSBAND Spouse's extraordinary/uncovered medical expenses: WIFE'S extraordinary medical expenses NOT covered by military or independent medical coverage will be paid % by HUSBAND and % by WIFE 1 HUSBAND'S extraordinary medical expenses NOT covered by military or independent medical coverage will be paid % by HUSBAND and % by WIFE MEDICAL COVERAGE FOR CHILDREN: end of coverage: CLHUSBAND will maintain medical coverage on the child(ren) until the child(ren) are no longer entitled to child support Basic coverage (including dental? (_) yes (_) no) 1D Major coverage (including dental? C) yes C) no) Ol WIFE will maintain medical coverage on the child(ren) until the child(ren) are no longer entitled to child support 1 Basic coverage (including dental? (_) yes (_) no) 1 Major coverage (including dental? C) yes C) no) or. Jeaves the military service, will purchase independent medical coverage for the child(ren) Children's extraordinary/uncovered medical expenses Children’s extraordinary medical expenses NOT covered by military or independent medical coverage will be paid: % by HUSBAND % by WIFE tl wpe Soe 21 Page 11 of 24 dopeLIFE INSURANCE PROVISIONS: DQ BUSBAND () WIFE is active duty military and will designate the minor child(ren) as the beneficiary of his/her SGLI insurance proceeds until the child(ren) reaches the age of majority and will name the other party as the Trustee for these proceeds to be held in trust for the benefit of the minor child(ren). DQ HUSBAND () WIFE is required to reimburse () HUSBAND (_) WIFE __% of the life insurance premiums Life insurance in the amount of $ shall be maintained on the life of the spouse providing child support. The children will be the irrevocable beneficiaries of said life insurance policy (a trust for the benefit of the children may be set up). Ifa life insurance policy is not maintained, the spouse's estate will be liable to the children for said amount. DQ) HUSBAND (_) WIFE is required to reimburse (.) HUSBAND (_) WIFE __% of the life insurance premiums s/he pays DD Each party is free to change life insurance policies as desired. 1 Other agreements on life insurance: JIA wpe ne 21 Page 12 of 24 App btDIVISION OF REAL PROPERTY Do you have a marital residence, land, buildings or other property affixed to land (time share)? D Yes No IfNO. skip to next section If YES, complete below: PROPERTY 1 1. Location: : (No) (street) City) (County) (State) 2. Title is currently held: 1 Solely by the HUSBAND 1D Solely by to WIFE 1 By both the HUSBAND and WIFE, as joint tenants with right of survivorship 1D Other (describe): 3. Date the property was acquired: (MM/DD/YYYY) 4, The Legal Title will be: D Transferred to the HUSBAND and WIFE as tenants in common D Transferred to the WIFE 1 Transferred to the HUSBAND D Left unchanged If there is to be a transfer of title When will transfer of title be executed: (MM/DD/YYYY) Will the transferee purchase the transferor's interest in property? TNo Yes IF YES, specify amount $ Iftitle is transferred, will the transferor continue to pay expenses of such property? ONo O Yes If YES, describe such expenses: 5. Regarding possession (who will reside in the property): 1D The WIFE is entitled to live in the property 1 The HUSBAND js entitled to live in the property 1 The (.) WIFE (_) HUSBAND may reside in the property until (MM/DD/YYYY) or until the property is sold, whichever occurs first ILA pee ne 21 Page 13 of 24 AppsFinancial compensation for occupancy: D None D Rent to other party $ O Monthly payment to lender 6. Financial obligation: 1 Paid in full 1 Installment payments 1. Lender Name: 2. Account No.: 1D ( HUSBAND (_) WIFE will be solely responsible for the mortgage payments HUSBAND and WIFE will be equally responsible for the mortgage payments CLHUSBAND will be responsible for _%, WIFE will be responsible for_% of the morigage payments For duration of the mortgage OR 1 Until the parties sell the property incident to this separation NOTE: If this is a joint mortgage obligation, the only way to be relieved from liability to the lender ifthe other party fails to pay is to have the mortgage company release you from the note. 7. Sale of property: If the property is to be sold: Date when sale must be final: (MM/YYYY) Division of proceeds of sale (describe) IA upd ne 21 Page 14 of 24 AxPROPERTY 2 (No) (street) (City) (County (State) 2. Title is currently held: 1D Solely by the HUSBAND D Solely by to WIFE 1 By both the HUSBAND and WIFE, as joint tenants with right of survivorship 1 Other (describe): 3. Date the property was acquired: (MM/DD/YYYY) 4, The Legal Title will be: 1D Transferred to the HUSBAND and WIFE as tenants in common 1 Transferred to the WIFE, Transferred to the HUSBAND Left unchanged If there is to be a transfer of title When will transfer of title be executed: (MM/DD/YYYY) Will the transferee purchase the transferor's interest in property? CONc Yes IFES, specify amount $ If title is transferred, will the transferor continue to pay expenses of such property? CINo Yes IFES, describe such expenses: 5. Regarding possession (who will reside in the property) 1 The WIFE is entitled to live in the property 1 The HUSBAND is entitled to live in the property 1 The (_) WIFE () HUSBAND may reside in the property until (MM/DD/YYYY) or until the property is sold, whichever occurs first Financial compensation for occupancy: DNone Di Rent to other party $ 1D Monthly payment to lender $ ILA wpa Jane 21 Page 15 of 24 Apps M6. Financial obligation: O Paid in full 1 Installment payments 1. Lender Name: 2. Account Ne 1) HUSBAND (_) WIFE will be solely responsible for the mortgage payments HUSBAND and WIFE will be equally responsible for the mortgage payments DI HUSBAND will be responsible for __%, WIFE will be responsible for __% of the morigage payments For duration of the mortgage OR 1 Until the parties sell the property incident to this separation NOTE: If this is a joint mortgage obligation, the only way to be relieved from liability to the lender if the other party fails to pay is to have the mortgage company release you from the note. 7. Sale of property: If the property is to be sold: Date when sale must be final: (MM/YYYY) Division of proceeds of sale (describe): ILA upd June 21 Page 16 of 24 Appx MDIVISION OF PERSONAL PROPERTY Its agreed between the parties that there is no property subject to disposition by this agreement (we have already divided all our personal property to our mutual satisfaction). 1 We have already divided all our personal property except the following and it will be divided as indicated below: Note: Do not list items valued under $100.00. A. VEHICLES (include year, make, model, and vehicle identification number): 1. HUSBAND Di WIFE isto receive Veh CUHUSBAND 1 WIFE will pay the remaining loan balance on this vehicle The balance owed is: $. Fi Account # on lot 2. HUSBAND 1 WIRE isto receive Vehicle: COHUSBAND O WIFE will pay the remaining loan balance on this vehicle The balance owed is 8. Financial Institutio Account # on loan: DLHUSBAND O WIFE isto receive Vehicle: CHUSBAND O WIFE will pay the remaining loan balance on this vehicle ‘The balance owed is: $ Financial Institution: Account # on loan: B. STOCKS, BONDS, MUTUAL FUNDS (Name) (Series/Account number) Will be the sole property of O HUSBAND 0 WIFE 2, " (Name) Geries/Account number) Willbe the sole property of E HUSBAND Of WIFE 3 " Wame) — Geries/Account number) Will be the sole property of ED HUSBAND Ef WIFE ILA ped June 21 Page 17 of 24 AppsC. BANK ACCOUNTS, CREDIT UNION ACCOUNTS, CERTIFICATES OF DEPOSIT 1. (lastitution Name) (Type of Account and No.) Funds in this bank account will be paid to J] HUSBAND 1] WIFE C1 Divided equally between both OOTHER 2, (Institution Name) (Type of Account and No.) Funds in this bank account will be paid to O HUSBAND 1 WIFE 1 Divided equally between both OOTHER 3. (Institution Name) (Type of Account and No.) Funds in this bank account will be paid to HUSBAND O WIFE C Divided equally between both OTHER D. PERSONAL PROPERTY, OTHER THAN PERSONAL CLOTHING: 1, HUSBAND to rex BRAND NAME SERIAL # 2, WIFE is to receive: a b, e JLA wpe Je 24 Page 18 of 24 App MDIVISION OF DEBTS: 1 It is AGREED between the parties that there are no debts subject to disposition by this agreement. 1 Debts will be distributed as follows: A. HUSBAND shall have and pay: Creditor ‘Type of Account and Number Balance Qwed B. WIFE shall have and pay: Creditor ‘Type of Account and Number Balance Owed C. HUSBAND and WIFE shall SHARE: Creditor my \d Number Balance Owed 1 1D The parties will each pay half | HUSBAND will pay__% and WIFE will pay__% 2 1 The parties will each pay half | HUSBAND will pay__% and WIFE will pay__% 3 1 The parties will each pay half HUSBAND will pay __% and WIFE will pay__% ILA uped Sune 21 Page 19 of 24 Apps MTAXES AND DEPENDENCY EXEMPTIONS FILING TAXES FOR CURRENT YEAR: A. If the dissolution is final before midnight 31 December, the parties are single and must file as such for the tax year. Otherwise the parties will file as: a w (_) C_) Single ) () Married filing jointly C_) () Married filing separately () () Head of Household For joint filing, the parties agree to Di Share payment of deficit equally Share payment of deficit proportionally to their income 1D Share refund equally D Share refund proportionally to their income O Other: FILING TAXES FOR FUTURE YEARS DEPENDENCY EXEMPTIONS AND CHILD TAX CREDIT: In the absence of an agreement between the patties, the general rule is that the custodial parent gets the dependency exemptions. A noncustodial parent providing child support may be entitled to dependency exemptions if a decree of divorce or written separation agreement so provide. 1D WIFE is to get the dependency exemptions HUSBAND is to get the dependency exemptions 1D WIFE and HUSBAND split the dependency exemptions** **1f the dependency exemptions are to be spli 1 AUSBAND will get the dependency exemptions for each (_) even (_) odd year and the WIFE will get the exemptions each (__) odd (_) even year (1 HUSBAND will claim the following children as exemptions on his income tax return each year and the WIFE, will claim the following children as exemptions on her ineome tax return: HUSBAND: WIFE: MA wpa Jane 28 Page 20 of 24 Appx MSURVIVOR'S BENEFIT PROGRAM, RETIREMENT BENEFITS, CLAIMS AGAINST ESTATE SURVIVOR'S BENEFIT PROGRAM (SBP) ELECTION 1 (_) HUSBAND (_) WIFE agrees upon retirement from the Armed Forces, to voluntarily elect to participate in the military sponsored Survivor's Benefit Program and to elect the (_) HUSBAND (_) WIFE as the beneficiary thereof at the (_) maximum rate available (__) minimum rate available (_) Other (please specify) (_) HUSBAND (__) WIFE will be responsible for paying the SBP premiums. 1 (_) HUSBAND (__) WIFE agrees to waive election to participate in the military sponsored Survivor's Benefit Program, RETIREMENT BENEFITS Pensions (including military retired pay) are divisible as marital property or community property. (The Uniformed Services Former Spouses Protection Act (USFSPA) allows states to divide “disposable” military retired pay). The portion of a pension earned during the marriage is property that may be divided and distributed between the parties under a Separation Agreement or by court order. Please consult your attorney for further explanation. Military and Civilian Pension Righ Name of Plan HUSBAND’S or WIFE'S Account # CLHUSBAND agrees to waive and give up all claims he may have for a part of WIFES military and/or civilian retirement income (to include IRAs) O WIFE agrees to waive and give up all claims she may have for a part of HUSBAND'S military and/or civilian retirement ineome (to include IRAs) OR D HUSBAND will pay to the WIFE __% of his civitian retirement income 1D WIFE will pay to the HUSBAND __% of her civilian retirement income OR 1 Settled by payment from HUSBAND to WIFE Amount: S ; Sum to be paid on or before: D Settled by payment from WIFE to HUSBAND Amount: $ Sum to be paid on or before: ILA sped Se 21 Page 21 of 24 Apps MACTIVE DUTY AWARDS 1 Spouse to receive a specific dollar amount. This provision safeguards any subsequent cost of living pay increases for the retiree (unless the spouse has the order modified each time a raise is received.) The specific dollar amount is S per month, 1 Spouse to receive a specific percentage. This provision gives the former spouse the benefit of subsequent cost of living adjustments. The specific percentage is % of the marital share of disposable military retired pay. O Military retired pay to be divided based on a formula. “The former spouse is awarded a percentage of the member's disposable military retired pay, to be computed by multiplying __% times a fraction, the numerator of which is months of marriage during the member's creditable military service, divided by the member’s total number of months of creditable military service.” Oi Military retired pay to be divided based on a hypothetical formula: ( Active duty hypothetical calculated as of time of division; may only be used for members who entered service BEFORE 09/01/80: “The former spouse is awarded ___% of the disposable military retired pay the member would have received had the member retired with the rank of and with years of creditable service on ” [Include in court order: On the date of the decree of divoree, dissolution, annulment or legal separation (add date) the member's military pay grade (rank) was and the member had years and months of erediable service]. ( Aetive duty hypothetical calculated as of time of division, for members who entered service AFTER 09/01/80: “The former spouse is awarded % of the disposable military retired pay the member would have received had the member retired with a retired pay base (High-3) of and with ‘years of creditable service on [Include in court order: On the date of the decree of divorce, dissolution, annulment or legal separation (add date) the member's military retired pay base (high-3) was (provide a dollar amount) and the member had years and months of creditable service]. JA upeid ne 24 Page 22 of 24 Ao MtRESERVE AWARDS WHEN THE MEMBER IS STILL DRILLING OO Eixed award: The former spouse is awarded (dollar amount) of the member's disposable military retirement pay. 1 Percentage award: The former spouse is awarded __% of the member’s disposable military retirement eee 1 Formula award: “The former spouse is awarded a percentage of the member's disposable military retired pay, to be computed by multiplying __% times a fraction, the numerator of which is reserve retirement points earned during the period of the marriage, divided by the member's total number of reserve retirement points earned.” 1 Military retired pay to be divided based on a hypothetical formula ‘O Reservist hypothetical calculated as of time of division; may only be used for members who entered service BEFORE 09/01/80: “The former spouse is awarded __% of the disposable military retired pay the ‘member would have received had the member become eligible to receive retired pay on >with the rank of » with reserve retirement points, and with years of service for basic pay purposes” [Include in court order: On the date of decree of divorce, dissolution, annulment or legal separation ___ (list the date) the member's military pay grade (rank) was and the member had (enter amount) reserve retirement points, and the member had years of service for basie pay (purposes (list amount of years and months). C Reservist hypothetical calculated as of time of division, for member’s who entered AFTER 9/8/80: “The former spouse is awarded __% of the disposable military retired pay the member would have received had the member become eligible to receive military retired pay with a retired pay base (High-3) of and with reserve retirement points on [Include in court order: On the date of the decree of divorce, dissolution, annulment or legal separation (add date) the member's military retired pay base (high-3) was (provide “@ dollar amount) and the member had enter amount) reserve retirement points]. 1 Ifthe member's disposable military retired pay is reduced as a result of disability payments, the member (_) WILL (__) WILL NOT indemnity the former spouse in the amount he or she would have received if there had been no reduction. CLAIMS AGAINST THE ESTATE OF THE OTHER SPOUSE: C1) HUSBAND agrees that the estate of WIFE will pass to the heirs of the WIFE as if the HUSBAND had died before the WIFE. HUSBAND further agrees not to contest the will of WIFE. Ol WIFE agrees that the estate of HUSBAND will pass to the heirs of the HUSBAND as if the WIFE had died before the HUSBAND. WIFE further agrees not to contest the will of HUSBAND. A wpe Jane 21 Page 23 of 24 Apps MOTHER: Please specify any other mutually agreed upon terms that were not covered by the above sections: The signatures of HUSBAND and WIFE below reflect they have discussed the contents of this worksheet. THIS WORKSHEET IS NOT A BINDING AGREEMENT HUSBAND (DATE) WIFE (DATE) ILA wpe Jase 21 Page 24 of 24 Appx