Revision A IN THE FOURTH CIRCUIT COURT FOR KNOX COUNTY, TENNESSEE ____________________________, Plaintiff, v. Docket No. ____________ ____________________________, Defendant. LOCAL RULE 28B VERIFIED STATEMENT STATE OF TENNESSEE COUNTY OF KNOX I (fill in your name), ______________________, have personal knowledge of the facts I state in this document, and after being duly sworn, I say the following things under oath: I. Facts About Me 1.1. I am (circle one) the plaintiff/defendant and (circle one) the Mother/Father of a child or children whose care is before this court. 1.2. I have filed a complaint for divorce (or I have filed a counter-complaint for divorce, or I have filed a post-divorce complaint), in which I have stated fully and accurately all jurisdictional facts required to be disclosed under statute. I have also filed a proposed Temporary Parenting Plan, a copy of which is attached hereto. II. Facts About Co-Parenting Authority and Co-Parenting Time 2.1. There are _______ minor child(ren) of this marriage (or of whom the other parent and I have legal co-parenting authority). Their names, genders, and birth dates are as follows: A. B. C. D. American LegalNet, Inc. www.USCourtForms.com 2.2. In the last five years, the child(ren)’s other parent and I shared co-parenting duties this way (circle Mother, Father, or “not applicable”): A. Mother/Father/not applicable prepared more than 50% of the child(ren)’s meals. B. Mother/Father/not applicable bathed and/or otherwise prepared the child(ren) for bed more than 50% of the time. C. Mother/Father/not applicable----took the child(ren) to medical appointments more than 50% of the time. D. Mother/Father/not applicable----readied the child(ren) for school more than 50% of the time. E. Mother/Father/not applicable----assisted the child(ren) with homework and other school assignments more than 50% of the time. F. Mother/Father/not applicable----did more than 50% of all communications with the child(ren)’s teacher(s). G. Mother/Father/not applicable----transported (or arranged transportation) for the child(ren) to attend school or daycare more than 50% of the time. H. Mother/Father/not applicable----transported (or arranged transportation) for the child(ren) to attend extracurricular activities more than 50% of the time. 2.3. Circle where applicable: I am employed/not employed----outside the home. My usual work schedule outside the home is as follows: _____________ (hours of day), __________________ (days of week). 2.4. Circle where applicable: The other parent is employed/not employed----outside the home. The other parent’s usual work schedule outside the home is as follows: __________ (hours of day), (days of week). 2.5. When the child(ren) are in my care but I cannot be with them, the following caregivers will be responsible for the child(ren): ___________________________________________________________________________________. 2 American LegalNet, Inc. www.USCourtForms.com 2.6. Based upon the information set forth above, (check one): I state that I have been the minor child(ren)’s primary caregiver and should remain so. I state that the other parent has been the primary caregiver and should remain so. I state that the other parent has been the primary caregiver, but that I should become the primary caregiver today for the reasons set out below. _____ I state that both of us have been extensively involved as caregivers for our child(ren) and that we should be equal primary caregivers for the reasons set forth below. 2.7 (Circle one) I / the other parent / both of us----should be designated the primary caregiver of the child/ren because it is in (his/her/their) best interest for the following reasons: _________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2.8. (If currently separated, please complete): We are currently exercising the following co- parenting time with the minor child(ren):___________________________________________________ ___________________________________________________________________________________. 2.9. As to the co-parenting time described in Local Rule of Court 26: A. The co-parenting time I propose (circle one) for me/for the other parent in my Proposed Temporary Parenting Plan is consistent with the schedule set forth in Local Rule 26; OR, B. The co-parenting time I propose is not consistent with the schedule set forth in Local Rule 26, but a deviation from Local Rule 26 is in the child(ren)’s best interest because: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3 American LegalNet, Inc. www.USCourtForms.com III. Facts About Child Support 3.1. My gross monthly income is $_________________. 3.2. The other parent’s income: A. The other parent’s gross monthly income is $_________________. The child support obligation I put into my Proposed Temporary Parenting Plan is consistent with the Tennessee Child Support Guidelines; OR, B. I have no specific knowledge of the other parent’s gross monthly income. Accordingly, the child support obligation I put in the Proposed Temporary Parenting Plan is based preliminarily on the following, with no presumption of correctness (check one): __ 1. Minimum wage only, 2. The statutory presumption of the ability to earn $28,145 per year. OR, __ C. I realize that all child support obligations are subject to adjustment by the child support Referee, and that either parent may seek an adjustment. 3.3. Income Documentation: A. The following documentation of my income is attached hereto as Exhibit A: (Circle where applicable): tax return; pay stub; affidavit of employer; other: _____________________________________________________________________. B. The following documentation of the other parent’s income is attached hereto as Exhibit B: (Circle where applicable): tax return; pay stub; affidavit of employer; other: _____________________________________________________________________. C. I have been unable to obtain documentation of the other parent’s income, but her/his last known income was $________________. This information is based on _______________________________________________________________________ _______________________________________________________________________ 4 American LegalNet, Inc. www.USCourtForms.com . IV. Facts Relevant to Submission of Affidavit 4.1. My proposed Temporary Parenting Plan is presented in good faith. It is reasonable under the circumstances of this case. It proposes provisions for the children that are in their best interest. I request that it be entered without a hearing as the pendente lite order of the court pursuant Tennessee Rules of Civil Procedure 65.07. 4.2. By signing this sworn document, I indicate that I fully understand that if I have made an intentional misstatement (Initial your understandings below): ______ A. I can be criminally prosecuted for perjury; ______ B. The Court can adopt the other parent’s Parenting Plan; ______ C. The Court can determine that I choose to put my own interests before those of my child(ren); ______ D. The Court can question my future trustworthiness; ______ E. The Court can Order me to pay the other parent's attorney fees and litigation expenses. By signing below, I am telling the Court that I have read and understood each provision in this document. This concludes my statement. _______________________________ (Name) 5 American LegalNet, Inc. www.USCourtForms.com STATE OF TENNESSEE COUNTY OF KNOX Personally appeared before me, a Notary Public in and for said County, the mother or father above, ___________________, showing that he/she is the above-named person, and after being duly sworn according to law, stated and acknowledged that she/he executed the foregoing instrument voluntarily and without undue influence or coercion, and that it was true to his/her best information knowledge, and belief. Witness my hand and official seal this the ____ day of _____________, 20___. ______________________________ Notary Public My Commission Expires: __________ EXHIBIT A (As To My Income) EXHIBIT B (As to Other Parent’s Income) 6 American LegalNet, Inc. www.USCourtForms.com