STATE OF TENNESSEE

 

COURT (Must be completed)

 

SHELBY COUNTY(Must be completed)

 

 

PERMANENT PARENTING PLAN ORDER

  _  Proposed    FORMCHECKBOX   Agreed    FORMCHECKBOX   Ordered by the Court

 

 

file no.

 

division

 

 

Plaintiff  (Name: First, Middle, Last)

 

  Mother               FORMCHECKBOX   Father

 

Defendant (Name: First, Middle, Last)

 
 FORMCHECKBOX   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                     FORMCHECKBOX    is a new plan.

                                     FORMCHECKBOX    modifies an existing Parenting Plan dated  FORMTEXT Type Date .

                                     FORMCHECKBOX    modifies an existing Order dated  FORMTEXT Type Date.

 

Child’s Name

Date of Birth

 

 

 

 

 

I.          RESIDENTIAL PARENTING SCHEDULE

 

A.        RESIDENTIAL TIME WITH EACH PARENT

The Primary Residential Parent is ______________________.

Under the above schedule each parent will spend the following number of days with the children:

            Mother                         Father                   days.

B.        DAY-TO-DAY SCHEDULE 

The __ mother  FORMCHECKBOX  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    FORMTEXT Start Day and Time  to  FORMTEXT End Day and Time  

 FORMCHECKBOX    every week    FORMCHECKBOX    every other week   ___ other: no exceptions.


 

The other parent shall also have responsibility for the care of the child or children at the additional parenting times specified below:

From    FORMTEXT Enter Additional Start Day and Time to  FORMTEXT Additional Other End Day and Time

 

 FORMCHECKBOX    every week    FORMCHECKBOX    every other week   ___ other: None

This parenting schedule begins ___ immediately or   FORMCHECKBOX  date of the Court’s Order.

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)

 

 

Passover 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:  FORMTEXT Enter Any Other Special Days

 

 

 

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  FORMTEXT Please enter other holiday start time.

D.        FALL VACATION (If applicable)

The day to day schedule shall apply except as follows.      

WINTER (CHRISTMAS) VACATION

The  FORMCHECKBOX  mother  FORMCHECKBOX  father shall have the child or children for the first period from the day and time school is dismissed until  FORMTEXT Please Type Date  at  FORMTEXT Please Type Time  FORMDROPDOWN   FORMCHECKBOX  in odd-numbered years   FORMCHECKBOX  in even-numbered years   FORMCHECKBOX  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.

Other agreement of the parents:  

F.         SPRING VACATION (If applicable)

The day-to-day schedule shall apply except as follows

G.        SUMMER VACATION

The day-to-day schedule shall apply except as follows:

 Is written notice required?    FORMCHECKBOX  Yes ___ No.    If so,  FORMTEXT Please Type Number of Days number of days.

 

H.        TRANSPORTATION ARRANGEMENTS

The place of meeting for the exchange of the child or children shall be.

Payment of long distance transportation costs (if applicable):  FORMCHECKBOX  mother  ___ father  FORMCHECKBOX  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:

 FORMCHECKBOX  Person or organization supervising:

 FORMCHECKBOX   Responsibility for cost, if any:   FORMCHECKBOX  mother  ___ father  FORMCHECKBOX  both equally.

J.         OTHER

The following special provisions apply:

II.         DECISION-MAKING

A.         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.

 

 

 

 

 

B.        MAJOR DECISIONS:   

Major decisions regarding each child shall be made as follows:

Educational decisions                      ___  mother      FORMCHECKBOX    father        FORMCHECKBOX  joint                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

                        Non-emergency health care ___  mother      FORMCHECKBOX    father        FORMCHECKBOX  joint                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

                        Religious upbringing             ___  mother      FORMCHECKBOX    father        FORMCHECKBOX  joint                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Extracurricular activities                   ___  mother      FORMCHECKBOX    father        FORMCHECKBOX  joint                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

                         

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

III.        FINANCIAL SUPPORT

 

A.         CHILD SUPPORT

 

Father’s gross monthly income is $  FORMTEXT Please Type Father's Gross Monthly Income.

Mother’s gross monthly income is $-0-.

 

1.   The final child support order is as follows:

a. The   FORMCHECKBOX  mother ___ father shall pay to the other parent as regular child
support the sum of $
FORMTEXT Type amount of Child Support  FORMCHECKBOX  weekly   ____ monthly   FORMCHECKBOX  twice per month 

 FORMCHECKBOX   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:  FORMTEXT Please Type Reason For Deviation

 

2.  Retroactive Support: A judgment is hereby awarded to  FORMCHECKBOX  mother   FORMCHECKBOX  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
 FORMTEXT Please Type Date of Child Support Start which shall be paid (including pre/post judgment interest) at the rate of $ FORMTEXT Please Type Rate of Payment per       FORMCHECKBOX  week  FORMCHECKBOX  month   FORMCHECKBOX  twice per month   FORMCHECKBOX   every two weeks until the judgment is paid in full.

 

3.  Payments shall begin on the  FORMTEXT Please Type Day of Payment Start day of  FORMTEXT Please Type Month of Payment Start, 20 FORMTEXT Please Type last two Digits of Year.

 

This support shall be paid:

 FORMCHECKBOX   directly to the other parent.

 FORMCHECKBOX   to the Central Child Support Receipting Unit, P. O. Box 305200, Nashville, Tennessee 37229, and sent to the other parent at: FORMTEXT Please Type Address of Receiving Parent.

      A Wage Assignment Order is attached to this Parenting Plan

 FORMCHECKBOX  by direct deposit to the other parent at  FORMTEXT Please Type Name of Bank Bank for deposit in account no.  FORMTEXT Please Type Account Number.

 FORMCHECKBOX  other: FORMTEXT Please Enter Any Other Information Here.

 

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.

B.        FEDERAL INCOME TAX EXEMPTION[*]

The __  mother  FORMCHECKBOX  father is the parent receiving child support.

 

The Mother shall claim the following children:

The Father shall claim the following children: _______________

 

The  FORMCHECKBOX  mother  FORMCHECKBOX  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:  FORMCHECKBOX  alternate years starting  FORMTEXT Type Start Date

____ each year  FORMCHECKBOX  other:  FORMTEXT Please Type Other Information.

 

The  FORMCHECKBOX  mother  FORMCHECKBOX  father will furnish IRS Form 8332 to the parent entitled to the exemption by February 15th 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 

 FORMCHECKBOX    maintained by the father 

 FORMCHECKBOX    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  FORMCHECKBOX   mother  ___   father    FORMCHECKBOX    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.

If available through work, the ___ mother   FORMCHECKBOX  father shall maintain dental, orthodontic, and optical insurance on the minor child or children.

E.        LIFE INSURANCE (Required for parent paying child support)

The  FORMCHECKBOX  mother  FORMCHECKBOX  father _ both shall insure his/her own life in the minimum amount of $100,000.00 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:  FORMCHECKBOX  the other parent ___ the other parent, as trustee for the benefit of the children, to serve without bond or accounting,  FORMCHECKBOX  other : FORMTEXT Please Type Other Information.

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 p