COMMONWEALTH OF MASSACHUSETTS _______________ , SS. DOCKET No. ___________________________Plaintiff/Petitioner ___________________________Defendant/Petitioner Separation Agreement The Parties to this Complaint/Petition are ___________________________________ and ________________________________________. In this document, they shall be referred to as __________________________ and_______________________________. The Parties were married on _________________ in _____________________________ (Date) (City/State) The following child[ren] was/were born to the parties during the marriage: 9 None born to the parties. ___________________________________ Name ___________________________________ Name ___________________________________ Name ___________________________________ Name _________________ Date of birth _________________ Date of birth _________________ Date of birth _________________ Date of birth The marriage of the parties has irretrievably broken down. This Separation Agreement shall settle all questions related to alimony, child support, division of property, health insurance, financial rights, and all child-related matters. 1 American LegalNet, Inc. www.FormsWorkFlow.com The Parties agree: 1. That neither party will charge or incur any debt for which the other party will be responsible. Neither party will use the other's name to obtain credit of any kind. 2. That both will waive any interest in the estate of the other, except as provided in this Agreement. 3. That both will do all things necessary to carry out the terms of this Agreement. 4. That this Agreement shall be interpreted under Massachusetts Law. 5. That each has had an opportunity to seek legal advice. That each believe this Agreement is fair, just, and reasonable. That each signs this Agreement freely and voluntarily. 6. That each party understands this Agreement and understand that no spoken or written correspondence outside of this document will have any force or effect. 7. That each party must pay their own legal fees and costs for this proceeding. 8. That neither party will stalk, harass, or interfere with the other party or the employment of the other party. 9. If a Judgment of Divorce should enter, this Agreement shall be made part of that Judgment by agreement of the parties and: 9 Merge in such Judgment 9 Survive in such Judgment and retain independent legal significance 9 Survive in such Judgment and retain independent legal significance except for the provisions relating to child support, child custody, and all other provisions relating to the children, and ______________________________ ______________________________________________________________ which provisions shall be merged in such Judgment. 10. The attached Exhibits A, B, C, D, E, F, G, H, I, and J (if applicable) shall be incorporated into this agreement. 2 American LegalNet, Inc. www.FormsWorkFlow.com Exhibit A Division of Marital Property Real Estate: 9 None owned. 1. The parties own the following real estate which shall be divided as follows: 2. The cost of maintaining the real estate (payment of mortgage, taxes, insurance, equity loans, etc.) shall be as follows: Personal Property: (Personal property includes, but is not limited to, cash, pensions, retirement plans, bank accounts, stocks, bonds, mutual funds, furniture, cars, boats, trailers, jewelry, and collections.) 9 The Parties have already divided between themselves all of their personal property and they are satisfied that the division was fair. 1. The Parties agree to divide their personal property as follows: 9 The parties have no retirement assets to divide. 3 American LegalNet, Inc. www.FormsWorkFlow.com 2. The Parties agree to divide their retirement benefits, including but not limited to IRA accounts, 401K, 403B, Annuities, Deferred Compensation, Pension Plans, as follows: 3. The parties understand that if they have not disclosed an asset, that asset is subject to being divided in the future. Each party has relied on the financial statement/s filed in this case by the other party. Debt: 9 1. The parties shall each be responsible for any debt that is listed in their name. 9 2. The parties have no marital debt. 9 3. The parties have the following debt that shall be paid as follows: 4 American LegalNet, Inc. www.FormsWorkFlow.com Exhibit B Alimony 9 The parties waive and will not seek alimony from each other now or in the future. 9 The parties agree that _________________________ shall pay alimony to _________________ in the amount of ___________ per ___________. The alimony shall terminate upon the remarriage of the party receiving the alimony, the death of the either party, the date of _____________________, or further order of the Court. 9 Past and present alimony is waived but future alimony shall remain open. Exhibit C Health and Dental Insurance 9Neither party currently has health insurance and/or has Mass Health. If/when health insurance becomes available to either party at a reasonable cost through an employer, they shall obtain health insurance for the benefit of the child[ren]. 9 The parties shall each be responsible for their own health insurance. 9 ______________________________ shall continue to maintain " health " dental insurance for the benefit of the child[ren] until emancipation so long as it is available at a reasonable cost. 9 _________________________________ shall continue to maintain " health " dental insurance for __________________________ provided that ___________________________ can be maintained on the existing plan as being eligible at no cost beyond a family plan or, if the children are emancipated, beyond the cost of the carrying party to ensure himself/herself. If there is an additional cost to maintain health insurance for the former spouse, the former spouse shall be responsible for the payment of that cost. 9 ______________________________ shall notify the other party immediately in the event of any change to the health and/or dental insurance status. 5 American LegalNet, Inc. www.FormsWorkFlow.com 9 ____________________________________ shall pay the first $250 per year of all unreimbursed medical, dental, optical, laboratory, prescription pharmaceutical, orthodontic and counseling expenses not covered by insurance for the child[ren]. After the first $250 has been paid, the parties shall equally share all like uninsured expenses for the children. Each party shall present the uninsured expense to the other party within 30 days of receipt of