Person Filing: Mailing Address: City, State, Zip: Phone Number: Representing Self SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO Petitioner's Name on the Petition for divorce, legal separation, or custody: Case Number: DO PROPOSED RESOLUTION STATEMENT Respondent's Name: [ ] DIVORCE/SEPARATION [ ] CUSTODY/PATERNITY I am the [ ] Petitioner or [ ] Respondent. TITLE IV-D CASE: [] [] I and/or my children receive or have received public assistance that may include AFDC, TANF, or AHCCCS. I have a case with the Division of Child Support Enforcement. MINOR CHILDREN: The following children are under 18, or are 18 and in high school, and are my and the other party's biological or adopted children: Name: Birthdate: Age: CHILD CUSTODY: I want custody as follows. [] The other party agrees. [] Joint Custody: Award the parents joint custody of the children as set forth in the Joint Custody Agreement we signed. No significant domestic violence has occurred between the parties. [ ] The Joint Custody Agreement is attached or [ ] the Joint Custody Agreement dated was filed previously. Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 8 Revised February 2011 [] Sole Custody: Award [ ] Mother or [ ] Father sole legal custody and physical custody of the children. Joint custody is not in the children's best interest because (you must fill in this blank if you ask for sole custody): PARENTING TIME: I want parenting time as follows. [] The other party agrees. [] Order This Parenting Time Plan: The children will be in Father's care at these times: At the start of Father's time with the children, [ ] Mother will drop them off or [ ] Father will pick them up at this time: at this location: The children will be in Mother's care at these times: At the start of Mother's time with the children, [ ] Father will drop them off or [ ] Mother will pick them up at this time: at this location: While we understand the court may enforce this drop-off and pick-up schedule, we will be reasonably flexible about it. Other scheduling arrangements: [] During summer months or school breaks longer than four days not listed in the holiday schedule below, the children will be in [ ] Mother's or [ ] Father's care. [] We each are entitled to an annual -week vacation with the children. We will work out the details of the vacation at least days in advance. [] Neither parent will travel with the children outside Arizona for longer than days without the prior written consent of the other parent or order of the court. We will inform each other of plans to travel out of the area with the children and of addresses and phone numbers where we and children can be reached during travel. Page 2 of 8 Revised February 2011 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Even Years Odd Years Mother Father Mother Father New Year's Eve [] [] [] [] New Year's Day [] [] [] [] Spring Vacation [] [] [] [] Easter [] [] [] [] Passover [] [] [] [] 4th of July [] [] [] [] Halloween [] [] [] [] Veteran's Day [] [] [] [] Thanksgiving [] [] [] [] Hanukkah [] [] [] [] Christmas Eve [] [] [] [] Christmas Day [] [] [] [] Winter Break [] [] [] [] Children's Birthdays [] [] [] [] [] Mother will have the children on Mother's Day and Father will have the children on Father's Day. [] Each parent will have the children on that parent's birthday. [] On three-day weekends, which include Martin Luther King Day, President's Day, Memorial Day, Labor Day, and Columbus Day, the children will remain in the care of the parent who has them for the weekend. Holiday times will begin and end as follows: Holidays: Phone access: [] Each parent may contact the children by phone during the children's normal waking hours. [] Other: Religion: [] Each parent may take the children to a place of worship of that parent's choice while the children are in that parent's care. [] The children may be instructed in the following faith: [] Religious arrangements do not apply to this Plan. We may change the parenting plan by written agreement only, except in an emergency. Reviewing the plan: We will review this Plan every necessary or desired changes. Other: months and ask the court for any Page 3 of 8 Revised February 2011 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com [] Order Supervised Parenting Time: Unsupervised parenting time would seriously endanger the children's physical, mental, moral, or emotional health because: Parenting time may take place only in the presence of another person, named as follows: Other restrictions on parenting time: The cost of supervised parenting time, if any, will be paid [ ] by the parent being supervised or [ ] by the custodial parent or [ ] equally by both parties. [] Order No Parenting Time: Even supervised parenting time with the other parent would seriously endanger the children's physical, mental, moral, or emotional health because: CHILD SUPPORT: Parent's Worksheet for Child Support Amount: [ ] The attached Worksheet or [ ] the Worksheet dated , filed previously, shows the financial factors necessary to calculate child support under the Arizona Child Support Guidelines. [] The other party agrees. Past Support: Past support should be paid by [ ] Mother or [ ] Father for the period of through in the amount of $ . [] The other party agrees. Medical, Dental, Vision Care for Minor Children: Mother should be responsible for providing [ ] medical [ ] dental [ ] vision care insurance. Father should be responsible for providing [ ] medical [ ] dental [ ] vision care insurance. [] Insurance is not available to either parent at a reasonable cost. So, [ ] mother [ ] father should pay $ a month to the other parent for medical support. For Custody/Paternity Cases: Direct Payments: I [ ] received or [ ] paid direct payments for support for the period of through in the amount of $ Page 4 of 8 Revised February 2011 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Past Medical Expenses: [ ] Mother or [ ] Father should pay the other party $ for the cost of pregnancy, childbirth, and/or the children's past medical expenses. [] The other party agrees. TAX EXEMPTIONS: I want our income tax dependency exemptions divided as follows. [] The other party agrees. Parent Entitled to Claim: Me My Spouse [] [] [] [] [] [] [] [] [] [] [] [] [] [] Child's Name Tax Yea