_______________________________ Name _____________________________________ Address _____________________________________ City State Zip Code _____________________________________ Phone Number PETITIONER PRO SE MONTANA _______________ JUDICIAL DISTRICT COURT _____________________ COUNTY In re the Parenting of: Cause No.: _________________ minor child(ren); ________________________, Petitioner, Petition for Establishment of Permanent Parenting Plan and ________________________, Respondent. The Petitioner respectfully submits the following: 1. Information about Petitioner a. Name: 2. Age: 3. Address: City: Date of Birth: State: d. Length of Residence in County: e. Length of Residence in Montana, if applicable: f. County: Occupation: Petition for Establishment of Permanent Parenting Plan, Page 1 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com Petition for Establishment of Permanent Parenting Plan, Page 2 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com 2. Information about Respondent a. Name: b. Age: c. Address: Date of Birth: City: State: d. Length of Residence in Montana, if applicable: f. 3. Length of Residence in County: e. County: Occupation: Relationship The parties were never married. 4. Pregnancy Choose One: [] The [ ] Petitioner/[ ] Respondent is not pregnant. [] The [ ] Petitioner/[ ] Respondent is pregnant. However, the [ ] Petitioner/ [ ] Respondent is not the father, and the child is not at issue in this proceeding. 5. The Child(ren) The Petitioner is the [ ] Mother/[ ] Father and the Respondent is the [ ] Mother/ [ ] Father of the following minor child(ren): Name (first and last) _________________________________ Date of Birth: / / Address ________________________________________________________________ Name (first and last) _________________________________ Date of Birth: / / Address ________________________________________________________________ Name (first and last) _________________________________ Date of Birth: / / Address ________________________________________________________________ Name (first and last) _________________________________ Date of Birth: / / Address ________________________________________________________________ Name (first and last) _________________________________ Date of Birth: / / Petition for Establishment of Permanent Parenting Plan, Page 3 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com Address ________________________________________________________________ If needed, attach additional sheets as Exhibit _____. 6. Jurisdiction over the Child(ren) This Court has jurisdiction to make a parenting determination regarding the minor child(ren) listed above. Choose One: [] The child(ren) has/have lived in Montana for at least six consecutive months immediately before the start of this proceeding. If a child is less than six months old, the child has lived in Montana since his/her birth. [] Montana was the home state of the child(ren) within six months of the start of this proceeding, and one parent continues to reside in Montana. [] The child(ren) and one parent have had significant connections to Montana, and substantial evidence about them is available here. [] The child(ren) is/are physically present in Montana, and the child(ren) has/have been abandoned or an emergency exists requiring the child(ren)’s protection. 7. Required Information Regarding the Child(ren) This proceeding will affect the custody of the minor child(ren) of the parties. The following information is required by M.C.A. § 40-7-110: a. During the last five years, the child(ren) have lived at the following places with the following persons. List each place the child(ren) have lived, the dates the child(ren) lived there, and all person(s) with whom the child(ren) lived: Address Dates with Whom Petition for Establishment of Permanent Parenting Plan, Page 4 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com Address Dates with Whom List the names and present addresses, if known, of the persons listed above, other than Petitioner and Respondent, with whom the child(ren) have lived in the last five years: Names Present Address(es) If needed, attach additional sheet(s) as Exhibit ____. b. Choose One: [] I have not participated as a party or witness or in any other capacity in any Petition for Establishment of Permanent Parenting Plan, Page 5 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com other proceeding concerning the custody of or visitation with the child(ren). [] I have participated as a [ ] party/ [ ] witness / [ ] other: _______________ in another proceeding concerning the custody of the child(ren). Court: Case No.: Date of Child Custody Determination: ____________________________. If needed, attach additional sheet(s) as Exhibit ____. Petition for Establishment of Permanent Parenting Plan, Page 6 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com c. Choose One: [] I know of no other proceeding that could affect the current proceeding. [] The following proceeding could affect the current proceeding: Nature of Proceeding: _________________________________________ Court: Case No.: If needed, attach additional sheet(s) as Exhibit ____. d. Choose One: [] I know of no other person (not a party to this action) that has physical custody of the child(ren), or who claims rights of legal custody, physical custody or visitation with the child(ren). [] The following person(s) have physical custody of the child(ren) or claim rights of legal custody, physical custody or visitation with the child(ren): ___________________________________________________________ ___________________________________________________________ 8. Parenting Plan It is in the best interest(s) of the minor child(ren) that the Court adopt the Petitioner’s Proposed Parenting Plan, filed separately from this Petition. 9. Child Support Order Choose One: [] Child support in the amount of $ ___________ per month per child has been established by the Montana Child Support Enforcement Division or another appropriate administrative agency or court. A copy of the Order is attached hereto as Exhibit ____. (Skip to Number 10.) or [] The [ ] Petitioner/ [ ] Respondent needs financial assistance from the [ ] Petitioner/ [ ] Respondent to support the minor child(ren) and requests that the Court enter the following proposed Child Support Order: a. The [ ] Petitioner/ [ ] Respondent shall pay $__________ per month per Petition for Establishment of Permanent Parenting Plan, Page 7 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com child. This amount was determined in accordance with the Montana Child Support Guidelines, worksheet attached hereto as Exhibit ___. b. The first payment is due the _____ day of __________________, 20____. Payments should continue until such time as each child reaches the age of 18 years and has completed high school, or attained the age of 19 years, or is emancipated by court order, whichever shall first occur. c. On or before the first of every month, payments should be made to (Choose One): [] The Child Support Enforcement Division. Immediate income withholding is appropriate. The [ ] Petitioner’s/[ ] Respondent’s income is subject to immediate income withholding under M.C.A. Title 40, Chapter 5, Parts 3 and 4. [] [ ] Petitioner/[ ] Respondent. This child support order should be exempt from immediate income withholding because . or [] Clerk of Court. This child support order should be exempt from immediate income withholding because . d. The Petitioner requests that the following warning be included in the Final Child Support Order: WARNING: If a parent is delinquent in payments, that parent’s income may be subject to income withholding procedures under MCA Title 40, Chapter 5, without need for any further action by the Court. Support is delinquent when it is 8 days overdue. e. Whenever the case is receiving services under Title IV-D of the Social Security Act, support payments must be paid through the Department of Public Health and Human Services Child Support Enforcement Division as provided in M.C.A. § 40-5-909. f. This order is subject to review and modification by the Department of Public Petition for Establishment of Permanent Parenting Plan, Page 8 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com Health and Human Services upon the request of the Department or a party under M.C.A. §§ 40-5-271 through 40-5-273, when the Department is providing services for enforcement under Title IV-D of the Social Security Act. g. The obligations to provide financial child support, provide medical care for a child, and provide or comply with parenting arrangements shall be independent of each other, and the failure or inability to provide one or more shall not reduce any other obligation. h. Each party should promptly inform the Court of any changes in the following information: (i) Name, social security number, mailing address, residential address, telephone number, and driver’s license number; and (ii) 1. Names, addresses, and telephone numbers of current employers. The Petitioner requests that the following warning be included in the Final Child Support Order: WARNING: In any subsequent child support enforcement action, on sufficient showing of diligent efforts to locate the party, due process requirements for notice and service may be met by delivering written notice by regular mail to the last address of the party or the party’s employer reported to the Court. 10. Medical Support Order Choose One: [] A Medical Support Order has been established by the Montana Child Support Enforcement Division or another appropriate administrative agency or court. A copy of the Order is attached hereto as Exhibit ____. (Skip to Number 11.) or [] Medical support is needed to cover the medical and dental expenses of the minor child(ren) of the parties. The Petitioner requests that the Court adopt the following Medical Support Order: Existing Coverage Petition for Establishment of Permanent Parenting Plan, Page 9 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com Choose All That Apply: [] The child(ren) are presently covered under the following insurance plan: Carrier Name: Policy No.: The [ ] Petitioner/[ ] Respondent shall continue to provide medical coverage through the plan as long as it is available at a reasonable cost, and as long as no other plan or individual insurance is available that will better serve the interests of the parties. [] The child(ren) is a/are recipient(s) of medical assistance under Title XIX of the federal Social Security Act (Medicaid). [] The child(ren) are not covered under an existing insurance plan. Contingency Medical Support If the minor child(ren) are either (i) covered by Medicaid, (ii) are not covered under an existing insurance plan, or (iii) if the existing coverage becomes no longer available, the following provisions shall apply: a. The Petitioner shall provide medical coverage through individual insurance or a health benefit plan for the child(ren), as long as it is available at reasonable cost, and as long as no other plan or individual insurance is available that will better serve the interests of the parties. b. The Respondent shall provide medical coverage through individual insurance or a health benefit plan for the child(ren), as long as it is available at reasonable cost, and as long as no other plan or individual insurance is available that will better serve the interests of the parties. c. If health benefit plans are available to both parties at a combined cost that is reasonable or cost-beneficial and with benefits that are complementary or compatible as primary and secondary coverage, both parties shall provide coverage for the child(ren). d. Coverage is presumed to be available at reasonable cost if the cost of premiums does not exceed 25 percent of the obligated party's total child support obligation when calculated under the child support guidelines Petition for Establishment of Permanent Parenting Plan, Page 10 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com without credit for the medical support obligation. e. If circumstances change and a party believes that corresponding changes in cost are not reasonable or cost-beneficial, the party may move to petition any appropriate tribunal for relief. Duties of the Parties a. The Petitioner shall be responsible for ____% and the Respondent shall be responsible for _____% of all medical expenses of the minor child(ren), including the costs of the premium for coverage, all co-payments and deductibles required for coverage, and any uncovered medical expenses. b. Each party shall promptly execute and deliver to the insurance provider all forms necessary to ensure the child(ren)'s continuous participation in insurance coverage. Each party shall timely submit claims for processing, verification, and payment. Each party shall provide the other party with identification cards or other methods for access to coverage. c. If a party receives a reimbursement but did not pay the underlying bill, that party shall promptly pay over the proceeds to the proper party. d. If the party responsible for providing medical insurance coverage for the child(ren) allows such coverage to lapse without securing a comparable replacement, that party shall be liable for all the child(ren)'s medical expenses and shall indemnify the other party, the Department of Public Health and Human Services, or any third-party custodian for the cost of obtaining medical coverage and medical expenses. e. Any liability for unpaid medical costs and expenses may be entered as a judgment for unpaid support against the obligated party. A party may apply to the Court for expedited enforcement procedures. 6. If an obligated party fails to pay a required premium, the other parent, the Department of Public Health and Human Services, or the custodian may advance the cost of premiums and keep benefits continually in force for the child. The advance should be entered as a judgment for unpaid child support in favor of the advancing party and against the obligated parent. Petition for Establishment of Permanent Parenting Plan, Page 11 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com g. The obligation to provide medical coverage for the child(ren) ceases only when the child support obligation ceases. h. The costs of providing individual insurance or a health benefit plan may not be used as a direct offset to the child support obligation. However, as provided by the child support guidelines, the costs may be considered in making or modifying a child support order. i. Each party shall promptly inform the Court of any changes in the following information: (i) If the child(ren) is/are covered by a health or medical insurance plan, the name of the plan, the policy identification number, and the name(s) of the person(s) covered; (ii) If the child(ren) is/are not covered by a health or medical insurance plan, whether health insurance coverage for the child(ren) is available through the party’s employer or other group, and if so, whether the employer or other group pays any portion of the coverage premium. j. A civil penalty not to exceed $25 per day may be imposed for an intentional violation of this medical support order or the provisions of M.C.A Title 40, Chapter 5, Part 8 or the regulations promulgated under that Part. k. The Petitioner requests that the following warning be placed in the Final Child and Medical Support Orders: WARNING: The obligations to provide medical care, provide financial child support, and provide or comply with visitation and custody arrangements are independent of each other, and the failure or inability to provide one or more does not reduce any other obligation. 11. Notice to the Department of Public Health and Human Services Choose One: [] The Department of Public Health and Human Services is not providing services to the parties or minor child(ren) of the parties under the provisions of Title IV-D of the Social Security Act. [] The Department of Public Health and Human Services is providing services to the Petition for Establishment of Permanent Parenting Plan, Page 12 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com parties or minor child(ren) of the parties under the provisions of Title IV-D of the Social Security Act. The Petitioner will notify the Montana Child Support Enforcement Division and the Office of the Attorney General of this proceeding. [] Not applicable. The Petitioner is not seeking to establish, enforce, or modify the parties’ previously established child support order. 12. Other Provisions . WHEREFORE, the Petitioner requests as follows: 1. That this Court adopt the Petitioner’s Proposed Parenting Plan, filed separately from this Petition; 2. That a Child Support Order be established, if requested above; 3. That a Medical Support Order be established, if requested above; 4. Other Provisions: __________________________________________________________ ; and 5. For such other and further relief as the Court deems just and proper. DATED this _______ day of ____________________, 20___. _____________________________________ Petitioner Pro Se _____________________________________ Print Name STATE OF MONTANA ) ): ss COUNTY OF _________________ ) _______________________________, being first duly sworn on oath, says that he/she Petition for Establishment of Permanent Parenting Plan, Page 13 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com is the Petitioner in the above-entitled proceeding; that he/she has read the foregoing Petition and knows the contents thereof; and that the matter, facts and things stated therein are true to the best of his/her knowledge and belief. _____________________________________ Petitioner Pro Se _____________________________________ Print Name SUBSCRIBED AND SWORN to before me this _____ day of ________________, 20____. (Seal) ___________________________________ Name (printed): ______________________ Notary Public for the State of Montana. Residing at __________________________ My Commission Expires________________ Petition for Establishment of Permanent Parenting Plan, Page 14 of 11 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 04/01/04 American LegalNet, Inc. www.FormsWorkflow.com