STATE OF TENNESSEE COURT (Must be completed) PERMANENT PARENTING PLAN ORDER PROPOSED AGREED ORDERED BY THE COURT PLAINTIFF (Name: First, Middle, Last) _____________________________ Mother Father COUNTY(Must be completed) FILE N0. _______ (Must be completed) DIVISION _____ DEFENDANT (Name: First, Middle, Last) _____________________________ Mother Father The mother and father will behave with each other and each child so as to provide a loving, stable, consistent and nurturing relationship with the child even though they are divorced. They will not speak badly of each other or the members of the family of the other parent. They will encourage each child to continue to love the other parent and be comfortable in both families. This plan is a new plan. modifies an existing Parenting Plan dated __________________. modifies an existing Order dated _________________________. Child’s Name I. A. Date of Birth RESIDENTIAL PARENTING SCHEDULE RESIDENTIAL TIME WITH EACH PARENT The Primary Residential Parent is ____________________________________ Under the schedule set forth below, each parent will spend the following number of days with the children: Mother _________ days Father _________ days B. DAY-TO-DAY SCHEDULE The G mother G father shall have responsibility for the care of the child or children except at the following times when the other parent shall have responsibility: From _______________________ to ______________________ Day and Time every week 07/14/05 Day and Time every other week other: _____________________. 1 American LegalNet, Inc. www.USCourtForms.com The other parent shall also have responsibility for the care of the child or children at the additional parenting times specified below: From _______________________ to ______________________ Day and Time every week Day and Time every other week This parenting schedule begins other: _____________________. ________________ or date of the Court’s Order. Day and Time C. HOLIDAY SCHEDULE AND OTHER SCHOOL FREE DAYS Indicate if child or children will be with parent in ODD or EVEN numbered years or EVERY year: MOTHER FATHER New Year’s Day Martin Luther King Day Presidents’ Day Easter Day (unless otherwise _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ coinciding with Spring Vacation) _______________________ _______________________ _______________________ Mother’s Day _______________________ Memorial Day (if no school)_______________________ Father’s Day _______________________ July 4th _______________________ Labor Day _______________________ Halloween _______________________ Thanksgiving Day & Friday _______________________ Children’s Birthdays _______________________ Other School-Free Days _______________________ Mother’s Birthday _______________________ Father’s Birthday _______________________ Other: ________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Passover Day (unless otherwise coinciding with Spring Vacation) A holiday shall begin at 6:00 p.m. on the night preceding the holiday and end at 6:00 p.m. the night of the holiday, unless otherwise noted here_____________________________. D. FALL VACATION (If applicable) The day to day schedule shall apply except as follows:____________________________ _____________________________________________beginning _________________. E. WINTER (CHRISTMAS) VACATION The mother father shall have the child or children for the first period from the day and time school is dismissed until December _____ at ____ a.m./p.m. in odd-numbered years in even-numbered years every year. The other parent will have the child or children for the second period from the day and time indicated above until 6:00 p.m. on the evening before school resumes. The parties shall alternate the first and second periods each year. 07/14/05 2 American LegalNet, Inc. www.USCourtForms.com Other agreement of the parents: _____________________________________________ F. SPRING VACATION (If applicable) The day-to-day schedule shall apply except as follows: ___________________________ _______________________________________________________________________ ___________________________________________beginning ___________________. G. SUMMER VACATION The day-to-day schedule shall apply except as follows: ___________________________ __________________________________________ beginning ____________________. Is written notice required? H. Yes No. If so, ________ number of days. TRANSPORTATION ARRANGEMENTS The place of meeting for the exchange of the child or children shall be: ______________ ______________________________________________________________________. Payment of long distance transportation costs (if applicable): mother father both equally. Other arrangements: _____________________________________________________. If a parent does not possess a valid driver’s license, he or she must make reasonable transportation arrangements to protect the child or children while in the care of that parent. I. SUPERVISION OF PARENTING TIME (If applicable) Check if applicable Supervised parenting time shall apply during the day-to-day schedule as follows: Place: _______________________________________________________________. Person or organization supervising: ________________________________________. Responsibility for cost, if any: mother father both equally. J. OTHER The following special provisions apply : _______________________________________________________________________ _______________________________________________________________________ ______________________________________________________________________. II. A. DECISION-MAKING DAY-TO-DAY DECISIONS Each parent shall make decisions regarding the day-to-day care of a child while the child is residing with that parent, including any emergency decisions affecting the health or safety of a child. 07/14/05 3 American LegalNet, Inc. www.USCourtForms.com B. MAJOR DECISIONS Major decisions regarding each child shall be made as follows: Educational decisions Non-emergency health care Religious upbringing Extracurricular activities __________________________ III. A. mother mother mother mother mother father father father father father joint joint joint joint joint FINANCIAL SUPPORT CHILD SUPPORT Father’s gross monthly income is $ _______ Mother’s gross monthly income is $ ________ 1. The final child support order is as follows: a. The mother father shall pay to the other parent as regular child support the sum of $_____________ weekly monthly twice per month every two weeks. The Child Support Worksheet shall be attached to this Order as an Exhibit.* If this is a deviation from the Child Support Guidelines, explain why: _________________________________________________________________ 2. Retroactive Support: A judgment is hereby awarded in the amount of $_______ to mother father against the child support payor representing retroactive support required under Section 1240-2-4.06 of the D.H.S. Income Shares Child Support Guidelines dating from ________________ which shall be paid (including pre/post judgment interest) at the rate of $_____________ per week month twice per month every two weeks until the judgment is paid in full. 3. Payments shall begin on the _____ day of _____________, 20___. This support shall be paid: directly to the other parent. to the Central Child Support Receipting Unit, P. O. Box 305200, Nashville, Tennessee 37229, and sent from there to the other parent at: ___________________________. A Wage Assignment Order is attached to this Parenting Plan. by direct deposit to the other parent at ____________________________ Bank for deposit in account no. ________________________. other:________________________________________________________________. The parents acknowledge that court approval must be obtained before child support can be reduced or modified. *Child Support Worksheet can be found on DHS website at http://www.state.tn.us/humanserv/is/incomeshares.htm or at your local child support offices. 07/14/05 4 American LegalNet, Inc. www.USCourtForms.com B. FEDERAL INCOME TAX EXEMPTION* The mother father is the parent receiving child support. The Mother shall claim the following children: ___________________________________ The Father shall claim the following children: ___________________________________ The mother father may claim the exemptions for the child or children so long as child support payments are current by the claiming parent on January 15 of the year when the return is due. The exemptions may be claimed in: alternate years starting ________ each year other: _________. The mother father will furnish IRS Form 8332 to the parent entitled to the exemption by February 15 of the year the tax return is due. C. PROOF OF INCOME AND WORK-RELATED CHILD CARE EXPENSES Each parent shall send proof of income to the other parent for the prior calendar year as follows: IRS Forms W-2 and 1099 shall be sent to the other parent on or before February 15. A copy of his or her federal income tax return shall be sent to the other parent on or before April 15 or any later date when it is due because of an extension of time for filing. The completed form required by the Department of Human Services shall be sent to the Department on or before the date the federal income tax return is due by the parent paying child support. This requirement applies only if a parent is receiving benefits from the Department for a child. The parent paying work-related child care expenses shall send proof of expenses to the other parent for the prior calendar year and an estimate for the next calendar year, on or before February 15. D. HEALTH AND DENTAL INSURANCE Reasonable health insurance on the child or children will be: maintained by the mother maintained by the father maintained by both Proof of continuing coverage shall be furnished to the other parent annually or as coverage changes. The parent maintaining coverage shall authorize the other parent to consult with the insurance carrier regarding the coverage in effect. Uncovered reasonable and necessary medical expenses, which may include but is not limited to, deductibles or co-payments, eyeglasses, contact lens, routine annual physicals, and counseling will be paid by mother father pro rata in accordance with their incomes. After insurance has paid its portion, the parent receiving the bill will send it to the other parent within ten days. The other parent will pay his or her share within 30 days of receipt of the bill. * NOTE: The child support schedule assumptions in the guidelines (1240-2-4-.03 (6)(b) ) assume that the parent receiving the child support will get the tax exemptions for the child. 07/14/05 5 American LegalNet, Inc. www.USCourtForms.com If available through work, the mother father shall maintain dental, orthodontic, and optical insurance on the minor child or children. E. LIFE INSURANCE If agreed upon by the parties, the mother father both shall insure his/her own life in the minimum amount of $_____________ by whole life or term insurance. Until the child support obligation has been completed, each policy shall name the following as sole irrevocable primary beneficiary: the other parent the other parent, as trustee for the benefit of the children, to serve without bond or accounting, other __________________________. IV. PRIMARY RESIDENTIAL PARENT (CUSTODIAN) FOR OTHER LEGAL PURPOSES The child or children are scheduled to reside the majority of the time with the mother father. This parent is designated as the primary residential parent also known as the custodian, SOLELY for purposes of any other applicable state and federal laws. If the parents are listed in Section II as joint decision-makers, then, for purposes of obtaining health or other insurance, they shall be considered to be joint custodians. THIS DESIGNATION DOES NOT AFFECT EITHER PARENT’S RIGHTS OR RESPONSIBILITIES UNDER THIS PARENTING PLAN. V. DISAGREEMENTS OR MODIFICATION OF PLAN Should the parents disagree about this Parenting Plan or wish to modify it, they must make a good faith effort to resolve the issue by the process selected below before returning to Court. Except for financial support issues including child support, health and dental insurance, uncovered medical and dental expenses, and life insurance, disputes must be submitted to: Mediation by a neutral party chosen by the parents or the Court. Arbitration by a neutral party selected by parents or the Court. The Court DUE TO ORDER OF PROTECTION OR RESTRICTIONS. The costs of this process may be determined by the alternative dispute process or may be assessed by the Court based upon the incomes of the parents. It must be commenced by notifying the other parent and the Court by written request certified mail other: ____________________. In the dispute resolution process: A. Preference shall be given to carrying out this Parenting Plan. B. The parents shall use the process to resolve disputes relating to implementation of the Plan. C. A written record shall be prepared of any agreement reached, and it shall be provided to each parent. D. If the Court finds that a parent willfully failed to appear without good reason, the Court, upon motion, may award attorney fees and financial sanctions to the prevailing parent. VI. RIGHTS OF PARENTS Under T.C.A. § 36-6-101 of Tennessee law, both parents are entitled to the following rights: 07/14/05 6 American LegalNet, Inc. www.USCourtForms.com (1) The right to unimpeded telephone conversations with the child at least twice a week at reasonable times and for reasonable durations; (2) The right to send mail to the child which the other parent shall not open or censor; (3) The right to receive notice and relevant information as soon as practicable but within twenty-four (24) hours of any event of hospitalization, major illness or death of the child; (4) The right to receive directly from the child’s school any school records customarily made available to parents. (The school may require a written request which includes a current mailing address and upon payment of reasonable costs of duplicating.) These include copies of the child’s report cards, attendance records, names of teachers, class schedules, and standardized test scores; (5) Unless otherwise provided by law, the right to receive copies of the child’s medical health or other treatment records directly from the physician or health care provider who provided treatment or health care. (The keeper of the records may require a written request which contains a current mailing address and the payment of reasonable costs of duplication.) No person who receives the mailing address of a parent as a result of this requirement shall provide such address to the other parent or a third person; (6) The right to be free of unwarranted derogatory remarks made about the parent or his or her family by the other parent to the child or in the presence of the child; (7) The right to be given at least forty-eight (48) hours notice, whenever possible, of all extra-curricular activities, and the opportunity to participate or observe them. These include the following: school activities, athletic activities, church activities and other activities where parental participation or observation would be appropriate; (8) The right to receive from the other parent, in the event the other parent leaves the state with the minor child or children for more than two (2) days, an itinerary including telephone numbers for use in the event of an emergency; (9) The right to access and participation in education on the same basis that is provided to all parents. This includes the right of access to the child for lunch and other activities. However participation or access must be reasonable and not interfere with day-to-day operations or with the child’s educational performance. VII. NOTICE REGARDING PARENTAL RELOCATION The Tennessee statute (T.C.A. § 36-6-108) which governs the notice to be given in connection with the relocation of a parent reads in pertinent part as follows: If a parent who is spending intervals of time with a child desires to relocate outside the state or more than one hundred (100) miles from the other parent within the state, the relocating parent shall send a notice to the other parent at the other parent’s last known address by registered or certified mail. Unless excused by the court for exigent circumstances, the notice shall be mailed not later than sixty (60) days prior to the move. The notice shall contain the following: (1) Statement of intent to move; (2) Location of proposed new residence; (3) Reasons for proposed relocation; and 07/14/05 7 American LegalNet, Inc. www.USCourtForms.com (4) Statement that the other parent may file a petition in opposition to the move within thirty (30) days of receipt of the notice. VIII. PARENT EDUCATION CLASS This requirement has been fulfilled by both parents mother father neither. Failure to attend the parent education class within 60 days of this order is punishable by contempt. Under penalty of perjury, we declare that this plan has been proposed in good faith and is in the best interest of each minor child and that the statements herein and on the attached child support worksheets are true and correct. (A notary public is required if this is a proposed plan by one parent rather than one agreed by both parents.) __________________________________ ___________________________________ Mother Date and Place Signed Sworn to and subscribed before me this ______ day of __________________, 20_____. My commission expires:________________ _______________________________ Notary Public __________________________________ Father __________________________________ Date and Place Signed Sworn to and subscribed before me this ______ day of __________________, 20_____. My commission expires:________________ _______________________________ Notary Public APPROVED FOR ENTRY: ________________________________ _________________________________ Attorney for Mother __________________________________________ Address __________________________________________ Address __________________________________________ Phone and BPR Number Attorney for Father ____________________________________________ Address ____________________________________________ Address ____________________________________________ Phone and BPR Number Note: The judge or chancellor may sign below or, instead, sign a Final Decree or a separate Order incorporating this plan. COURT COSTS (If applicable) Court costs, if any, are taxed as follows: _____________________________________________. It is so ORDERED this the ________ day of ____________, ______. Judge or Chancellor 07/14/05 8 American LegalNet, Inc. www.USCourtForms.com