Parenting Plan Order Form – Fill Out and Use This PDF

	STATE OF TENNESSEE	COURT (Must be completed)	COUNTY(Must be completed)
	PERMANENT PARENTING PLAN ORDER		FILE N0. _______
			(Must be completed)
	฀ PROPOSED ฀ AGREED ฀ ORDERED BY THE COURT		DIVISION _____

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 _________________________.

I.RESIDENTIAL PARENTING SCHEDULE

A. 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	Day and Time
฀ every week ฀ every other week	฀ other: _____________________.

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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

Day and Time

฀every week ฀ every other week ฀ other: _____________________.

This parenting schedule begins ฀ ________________ 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)	_______________________	_______________________
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: _______________________________________		_______________________

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.

Other agreement of the parents: _____________________________________________

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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? ฀ Yes ฀ No. If so, ________ 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): ฀ 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.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.

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B.MAJOR DECISIONS

Major decisions regarding each child shall be made as follows:

Educational decisions	฀ mother	฀	father	฀ joint
Non-emergency health care	฀ mother	฀	father	฀ joint
Religious upbringing	฀ mother	฀	father	฀ joint
Extracurricular activities	฀ mother	฀	father	฀ joint
__________________________ ฀ mother		฀	father	฀ joint

III.FINANCIAL SUPPORT

A.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. ________________________.

฀income assignment not required; Explanation:_______________________________.

฀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/isdocuments.html or at your local child support offices.

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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.

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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 child/children as sole irrevocable primary beneficiary, with the ฀ other parent ฀ other _________________, as

trustee for the benefit of the child(ren), to serve without bond or accounting.

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.

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VI. RIGHTS OF PARENTS

Under T.C.A. § 36-6-101 of Tennessee law, both parents are entitled to the following rights:

(1)The right to unimpeded telephone conversations with the child at least twice a week at reasonable times and for reasonable durations. The parent exercising parenting time shall furnish the other parent with a telephone number where the child may be reached at the days and time specified in a parenting plan or other court order or, where days and times are not specified, at reasonable times;

(2)The right to send mail to the child which the other parent shall not destroy, deface, open or censor. The parent exercising parenting time shall deliver all letters, packages and other material sent to the child by the other parent as soon as received and shall not interfere with their delivery in any way, unless otherwise provided by law or court order;

(3)The right to receive notice and relevant information as soon as practicable but within twenty-four (24) hours of any hospitalization, major illness or injury, or death of the child. The parent exercising parenting time when such event occurs shall notify the other parent of the event and shall provide all relevant healthcare providers with the contact information for the other parent;

(4)The right to receive directly from the child's school any educational records customarily made available to parents. Upon request from one parent, the parent enrolling the child in school shall provide to the other parent as soon as available each academic year the name, address, telephone number and other contact information for the school. In the case of children who are being homeschooled, the parent providing the homeschooling shall advise the other parent of this fact along with the contact information of any sponsoring entity or other entity involved in the child's education, including access to any individual student records or grades available online. The school or homeschooling entity shall be responsible, upon request, to provide to each parent records customarily made available to parents. The school may require a written request which includes a current mailing address and may further require payment of the reasonable costs of duplicating such records. These records 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 treating physician or healthcare provider. Upon request from one parent, the parent who has arranged for such treatment or health care shall provide to the other parent the name, address, telephone number and other contact information of the physician or healthcare provider. The keeper of the records may require a written request including a current mailing address and may further require payment of the reasonable costs of duplicating such records. No person who receives the mailing address of a requesting 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 such parent or such parent's family by the other parent to or in the presence of the child;

(7)The right to be given at least forty-eight (48) hours notice, whenever possible, of all extracurricular school, athletic, church activities and other activities as to which parental participation or observation would be appropriate, and the opportunity to participate in or observe them. The parent who has enrolled the child in each such activity shall advise the other parent of the activity and provide contact information for the person responsible for its scheduling so that the other

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parent may make arrangements to participate or observe whenever possible, unless otherwise provided by law or court order;

(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 forty-eight (48) hours, an itinerary which shall include the planned dates of departure and return, the intended destinations and mode of travel and telephone numbers. The parent traveling with the child or children shall provide this information to the other parent so as to give that parent reasonable notice; and

(9)The right to access and participation in the child's education on the same bases that are provided to all parents including the right of access to the child during lunch and other school activities; provided, that the participation or access is legal and reasonable; however, access must not interfere with the school's day- to-day operations or with the child's educational schedule.

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:

After custody or co-parenting has been established by the entry of a permanent parenting plan or final order, if a parent who is spending intervals of time with a child

desires to relocate outside the state or more than fifty (50) 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

(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

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__________________________________	__________________________________
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	Attorney for Father
__________________________________________	____________________________________________
Address	Address
__________________________________________	____________________________________________
Address	Address
__________________________________________	____________________________________________
Phone and BPR Number	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

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