Fillable Printable Permanent Parenting Plan Order - Tennessee
Fillable Printable Permanent Parenting Plan Order - Tennessee
Permanent Parenting Plan Order - Tennessee
07/01/2013
1
STATE
OF
TENNESSEE
COURT
(Mus t be complet ed)
COUNTY
(Must be completed)
PERMANENT PARENTI NG P LAN ORDER
PROPOSED AGREED ORDERE D BY THE COURT
FILE N0. _______
(Must be completed)
DIVISION _____
P
LAINTIFF (Name: First, Mi ddle, Last)
_____________________________
Mother Father
D
EFENDANT
(Name: Firs t, 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 pl an is a new plan.
modifies an existi ng Paren ti ng Plan dat ed ___ ______ __ ______ _ .
modifies an existing Order dated _________________________.
Child’s Name
Date of Birth
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 S CHEDULE
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:
Fr om _____ __________________ t o ____ ___ ___ ____________
Day an d 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:
Fr om _____ __________________ t o ____ ___ ___ ____________
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. HOLID AY 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
coi ncidi ng with S pri ng Vacati on)
_______________________ _______________________
Passover Day (unles s otherwis e
coi ncidi ng with S pri ng Vacati on)
_______________________ _______________________
Mother’s Day _______________________ _______________________
Memorial Day (if no school)_______________________ _______________________
Father’s Day _______________________ _______________________
July 4
th
_______________________ _______________________
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 nig ht 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 schoo l 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 da y-to-day schedule shall apply except as follows: ___________________________
_______________________________________________________________________
___________________________________________beginning ___________________.
G. SUMMER VACATION
The day-to-day schedule shall apply except as follows: ___________________________
__________________________________________ beg inni ng ______ ___ _____ ___ ___.
Is written notice required? Yes No. If so, ________ number of days.
H. T RANSPOR TATION 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 arr a ng eme nts : _ _______________________________________ ___ ___ __ _____.
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. SUPERVI SION OF PARENTING TI ME (If applicable)
Che ck if appli cab le
Supervised parenting time shall apply during the day-to-day schedule as foll ows:
Place: _______________________________________________________________.
Person or organization supervising: ________________________________________.
Responsibility for cost, if any: mother father bot h eq ual ly.
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 DECI SIONS
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 S UPPORT
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 Ex hi bit.*
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 th e other par e n t 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
reduc e d 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 supp ort of fic es .
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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 Fo rms 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 chi l d care expenses shall send proof of expenses to the
other par en t for the prior calendar year and an esti mat e for t he next cal end ar 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. LIF E 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
trus tee for the benefit of the child(ren), to serve without bond or accounting.
IV. PRI MARY RESIDENT IAL 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 T HIS PARENTING PLAN.
V. DISAGREEMENTS OR MODIFICATION OF PLAN
Should the parents disagree about this Parenting Plan or wish to modif y 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 PROTECTI ON OR RE STRICTIONS.
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 tim es 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
custom arily 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 standardi zed tes t s cor es ;
(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) T he righ t 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. T his in cludes 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 RE LOC ATION
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 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 th e fol lowing :
(1) State ment o f in ten t to move;
(2) Location of proposed new residence;
(3) Reasons for pro posed relocat ion; 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.
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VIII. PARENT EDUCATION CLASS
This requirement has been fulfilled by both parent s 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 Pl ac e Signed
Sworn to and subscribed before me this ______ day of __________________, 20_____.
My comm ission expires:________________ _______________________________
Notary Public
__________________________________ _____ ___ __ ________________________
Father Date and Place Signed
Sworn to and subscribed before me this ______ day of __________________, 20_____.
My commissi on expires: ________________ _______________________________
Notary Public
APPROVED F OR ENTRY:
________________________________ _________________________________
Attorney for Mother Attorne y for Fath er
__________________________________________ ____________________________________________
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 tax ed as foll ows:
_____________________________________________.
It is so ORDERED this the ________ day of ____________, ______.
Judg e or Ch ancel l or
