Cmmnwealth f Massachusetts The Trial Curt Prbate and Family Curt epartment Wrcester ivisin, ss. cket N. -------- SEPARATION AGREEMENT (APPLICABLE TO ALL IVORCES ) Party A v. Party B (Name f Party A) (Street Address) (referred t as the Party A), and (Name f Party B) (City/Twn, State, Zip) f ------------------------------- (Street Address) (City/Twn, State, Zip) (referred t as Party B). The parties were married in:. (City/Twn, State, Zip) n I / and last lived tgether at (ate f Marriage) (Street Address) --------------------- -n / / (City/Twn) (State) (Zip) when an irretrievable breakdwn f the marriage ccurred. Page 1 f 19
CHILREN N children were brn f this marriage r were legally adpted by bth parties. The fllwing children brn f this marriage, r by legal adptin f bth parties, are nt yet emancipated because they are under the age f eighteen years OR are between the ages f 18 and 23 years and are dependent n the parties fr supprt: CHIL'S NAME ATE OF BIRTH The fllwing children brn f this marriage are ver the age f eighteen years AN are emancipated, as he/she/they are n lnger dependent n the parties fr supprt. CHIL'S NAME ATE OF BIRTH This Separatin Agreement is made inrder t settle and determine: a) the prperty and supprt rights f Party A and Party B; and b) the care, custdy, supprt, maintenance and educatin f the minr and/r dependent child(ren) f this marriage (attach Schedule A); and c) all ther rights and bligatins arising frm the marital relatinship. Incnsideratin f the mutual prmises cntained in this Separatin Agreement, Party A and Party B agree t the terms cntained in this Agreement. Page 2 f 19
PROPERTY IVISION AN EBTS A. Real Estate: Neither party hlds any interest in real estate. The parties have already divided their interest in the marital hme lcated at: (Street Address, Twn, State, Zip Cde) The parties agree t have the real estate appraised and listed fr sale by /!. The expenses shall be paid by and the prceeds frm the sale shall be divided as fllws: --------------------------- Said prperty is t be sld under the terms and cnditins f a shrt sale. Bth parties shall cperate with all interested parties regarding the listing f the prperty and sale. Said prperty shall be refinanced by Party A/Party B n r befre //. Inthe event that Party A/Party B is unable t refinance, then the parties shall: Party A/Party B shall remain in the hme until / /., at which time: B. Persnal Prperty (including mtr vehicle, excluding bank accunts): The parties hereby agree that: There has been a full and satisfactry divisin f all ther persnal prperty and each party shall hld full right, title and interest in all items f persnal prperty nw in their respective pssessin. The parties have persnal prperty in the pssessin f the ther r a third party. Retrieval f any and all persnal prperty in the pssessin f the ther, r any third party, shall be btained by / / at 5:00 P.M., unless therwise agreed upn, in writing, by bth parties t this agreement. Bth parties hereby waive all rights, title and wnership, if any persnal prperty is nt claimed by said date and time. Page 3 f 19
Party A shall have full right, title and interest in the fllwing items: Party B shall have full right, title and interest in the fllwing items: C. Pensin I Retirement Benefits: The parties have n retirement r pensin benefits t be divided. Party A/Party B shall transfer (amunt r percentage), adjusted fr gains r lsses as f the date f transfer, f the accunt (name f financial institutin and last 4 digits f accunt #) t Party A/Party B n (date) by a Qualified mestic Relatins Order. The parties shall cperate with ne anther t prepare any and all necessary dcuments fr this transfer. The parties shall equally share the cst f preparatin and all ther expenses assciated with this transfer. Party A/Party B r third-party '-------------' name shall be respnsible fr the preparatin f said Qualified mestic Relatins Order. Party A and Party B shall each keep their respective retirement accunts as listed in their financial statements dated --------- The retirement r pensin benefits f the parties shall be divided as fllws: Page 4 f 19
. Stck /Bnds (list values, shares, divisin) The parties have n interest in stcks r bnds. The stcks and bnds f the parties shall be divided as fllws: E. Bank Accunts: The parties hereby agree that: Party A shall have full right, title and interest in the bank accunts and assets ( excluding retirement accunts) in his/her name and listed n his/her financial statement dated I I r as fllws: Party B shall have full right, title and interest in the bank accunts and assets ( excluding retirement accunts) in his/her name and listed n his/her financial statement dated I I r as fllws: F. ebt: The parties have n jint bank accunts. Party A will be respnsible fr his individual debts and liabilities as listed n his financial statement dated I I -- Party B will be respnsible fr her individual debts and liabilities as listed n her financial statement dated I I -- The marital debts f the parties shall be paid as fllws (creditr, amunt wed, divisin): Page 5 f 19
Each party hereby waives past and present alimny frm the ther. Bth parties reserve the right t future alimny. Each party hereby waives past, present, and future alimny frm the ther. Party A - Party B shall pay t Party A - Party B the sum f $ each and every week, beginning I I,as alimny. Payments f alimny shall end: n I I (date) when the fllwing event(s) ccur(s): HEALTH INSURANCE FOR PARTIES Party A's health insurance cverage will be prvided: by Party A by Party B fr s lng as it is available t him/her, and if there is any additinal cst t cntinued cverage fr the insurance: The additinal ut f pcket cst shall be paid by Party A I Party B. Payment f the additinal cst shall be made n r befre ------- OR Party A shall have the ptin f chsing t prvide his/her wn health insurance cverage and shall ntify Party B in writing if he/she elects t d s. Party B's health insurance cverage will be prvided: by Party B by Party A fr s lng as it is available t him/her, and if there is any additinal cst t cntinued cverage fr the insurance: The additinal ut f pcket cst shall be paid by Party A I Party B. Payment f the additinal cst shall be made n r befre,, OR Party B shall have the ptin f chsing t prvide his/her wn health insurance cverage and shall ntify Party A in writing if he/she elects t d s. Page 6 f 19
UNINSURE MEICAL EXPENSES FOR EACH PARTY The cst f all reasnable uninsured and unreimbursed medical, dental, hspital, ptical, prescriptin medicatin and therapeutic cunseling services shall be paid: By each party fr himself/herself. Party A shall pay t Party B % f said expenses r $ fr Party B. Party B shall pay t Party A % f said expenses r $ fr Party A. Cpies f all invices r bills shall be prvided t the paying party within days receipt. All payments t be made directly t the ther party within days freceipt f the bill(s). LIFE INSURANCE Party A shall maintain life insurance in the face amunt f $ nammg as the beneficiary, and shall be required t keep the life insurance in effect until Party B shall maintain life insurance in the face amunt f $ nammg as the beneficiary, and shall be required t keep the life insurance in effect until Neither party shall be required t maintain life insurance fr the benefit f the ther. OTHER PROVISIONS RESUMING FORMER NAME As requested in the Cmplaint fr ivrce, ----------- seeks t resume his/her frmer name, ------------------ GOVERNING LAW This Separatin Agreement shall be cnstrued and gverned accrding t the laws f the Cmmnwealth f Massachusetts. Page 7 f 19
FULL ISCLOSURE OF ASSETS AN LIABILITIES Party A and Party B hereby represent that they have each made full disclsure t the ther party f their individual assets. Each party repreents that Party A I Party B has prvided the ther with a current financial statement n the frm prmulgated pursuant t Supplemental Prbate Curt Rules, Rule 401, which disclses fully and cmpletely all f Party A I Party B's incme, expenses, assets and liabilities. By executing this Separatin Agreement, the parties represent that the terms and prvisins f this agreement are fair, just and reasnable and are nt the prduct f fraud, cercin r undue influence, and that each signs this agreement freely and vluntarily. SUBMISSION OF AGREEMENT TO COURT Party A and Party B each agree that this Separatin Agreement shall be submitted t the Wrcester ivisin f the Prbate & Family Curt fr a Judge's apprval f the terms and entry f a Judgment f ivrce. The parties further agree that the terms and prvisins f this Separatin Agreement shall be: (Chsefrm thefllwing) incrprated and merged int the Judgment f ivrce Nisi f the Curt. incrprated, but nt merged, int the Judgment f ivrce Nisi, and shall remain as an independent cntract between the parties. incrprated, but nt merged, int the Curt's Judgment, and shall survive and remain as an independent cntract, except fr the terms and prvisins relating t the care, custdy, supprt and educatin f the minr child(ren), (attach Schedule A) which terms nd prvisins shall merge in said Judgment. incrprated, but nt merged, int the Curt's Judgment, and shall survive and remain as an independent cntract, except fr the terms and prvisins relating t alimny and medical insurance (strike inapplicable term) which terms and prvisins shall merge in said Judgment. Page 8 f 19
EXECUTION Signed n. (ate) Party A's Signature Party A's PRINT NAME Signed n (ate) Party B's Signature Party B PRINT NAME **************************************************** ************************ Cmmnwealth f Massachusetts Wrcester ivisin, ss. ate: ------------ Then persnally appeared the abve-named --------------- (Name) and acknwledged that HE I SHE signed the freging as HIS I HER free act and deed. Ntary Public - My Cmmissin Expires: **************************************************************************** Cmmnwealth f Massachusetts Wrcester ivisin, ss. ate: ------------ Then persnally appeared the abve-named --------------- (Name) and acknwledged that HE I SHE signed the freging as HIS I HER free act and deed. Ntary Public - My Cmmissin Expires: Page 9 f 19
SCHEULE A - CHIL RELATE MATTERS LEGAL CUSTOY (which parent(s) make(s) majr decisins fr the child(ren) fr health care, religin, educatin, etc.). The Parties shall have shared legal custdy f the minr child(ren). The parties agree they are able t cmmunicate and make jint decisins regarding their child(ren). Party A shall have sle legal custdy f the minr child(ren). Party B shall have sle legal custdy f the minr child(ren). PHYSICAL CUSTOY (primary residence f the children and which parent makes the day-t-day decisins regarding the child(ren). Party A shall have sle physical custdy f the minr child(ren). Party B shall have sle physical custdy f the minr child(ren). The Parties shall have shared physical custdy f the minr child(ren) in accrdance with the PARENTING SCHEULE specified belw.* The Parties shall have split physical custdy as fllws: Party B will have physical custdy f AN Party A will have physical custdy f (Name f Third Party) shall have physical custdy f *PARENTING SCHEULE The parties may agree t parenting time ther than set frth belw. Hwever, in the event they cannt agree, the terms f this rder/judgment shall apply. Party A's parenting time with the children shall be as fllws: Alternating weekends frm at t at The first weekend fr Party A shall begin n and shall be alternating thereafter. Page 10 f 19
When there is a Mnday hliday, the weekend shall be extended until Mnday at Other prvisins (t include weekday parenting time) Party B's parenting time with the child(ren) shall be as fllws: Alternating weekends frm at A.M./P.M. t -------at A.M./P.M.. The first weekend fr Party B shall begin n and shall be alternating thereafter. When there is a Mnday hliday, the weekend shall be extended until Mnday at --------- A.M.IP.M. Other prvisins (t include weekday parenting time) The hliday and vacatin schedule shall supercede the regular parenting schedule. A week f summer r schl vacatin shall be seven days, t include a parent's regularly scheduled weekend with the child(ren). Page 11 f 19
Schl vacatins shall be shared as fllws: At such time as the child(ren) are f schl age,--------- shall have February schl vacatin in dd years. shall have the even years. At such time as the child(ren) are f schl age,---------shall have April schl vacatin in dd years. shall have the even years. Summer vacatin shall be as fllws: --------- summer in dd years. --------- summer in even years. -shall have first ptin fr -shall have first ptin fr weeks in the weeks in the The parties shall mutually agree/cmmit t summer vacatin in writing by May 1 each year. Summer vacatin weeks shall be taken cnsecutively, as fllws: Summer vacatin weeks shall be taken nn-cnsecutively. The child(ren)'s birthday shall be as fllws: The parties' birthdays shall be shared as fllws: Page 12 f 19
Hlidays t be as fllws: shall have Thanksgiving in dd years frm at A.M./P.M. t--------at A.M./P.M. --------shall have Thanksgiving in even years frm at A.M./P.M. t at A.M./P.M.. Other Hlidays. --------shall have Mther's ay frm A.M./P.M. t A.M./P.M.. shall have Father's ay frm A.M./P.M. t A.M./P.M.. The parties shall share the ecember Hliday(s)Nacatin as fllws: Ineven years, ---------shall have ecember 24th frm t ecember 25th at, and shall have ecember 25th frm - t ecember 26th at. This schedule shall be reversed in dd years. ----------shall have Easter in dd years frm t (Party A/Party B) Page 13 f 19
-------- - shall have Easter in even years frm t (Party A/Party B) Any changes t the abve parenting plan/vacatin/hliday schedule may be mutually arranged between the parties upn advance ntice. The parties shall meet t exchange f the child(ren) at: parenting time. shall transprt the children at the beginning f the abve time. shall transprt the children at the end f the abve parenting Additinal prvisins: Neither party shall permanently relcate with the child(ren) frm the Cmmnwealth f Massachusetts withut written permissin f the ther r further rder f the Curt. CHIL SUPPORT Starting --"I'- "I'-, Party A I Party B shall pay child supprt as fllws: The sum f $ (Amunt) each and every week - tw weeks - mnth. (Circle One) Child supprt shall be payable directly t Party A I Party B; OR Child supprt shall be payable by Party A I Party B thrugh the epartment f Revenue (OR) by wage assignment; OR Child supprt shall be payable by Party A I Party B thrugh the epartment f Revenue (OR), wage assignment being suspended. Page 14 f 19
Neither party shall pay child supprt t the ther party fr the fllwing reasns: The parties acknwledge that the child supprt rder which wuld result frm the applicatin f the Child Supprt Guidelines is: per week. The agreed amunt f supprt is different than Guidelines amunt because: Child Supprt fr a child(ren) ver the age f eighteen wh is/are principally dmiciled with ne parent and dependent upn the parents fr supprt: Shall cntinue at the abve amunt until - Shall cntinue at the abve amunt until emancipatin, per Massachusetts General Law. Shall increase t $ Shall decrease t $ - and terminate n - - - and terminate n - - Shall be determined by the curt at the hearing n a Cmpliant fr Mdificatin. MEICAL INSURANCE FOR CHIL(REN) The Party A I Party B (Circle One) shall be respnsible fr prviding health insurance fr the minr child(ren): Thrugh Party A's I Party B's emplyment OR By btaining and maintaining a private health insurance plicy OR Thrugh current cverage under Mass Health. Either party shall btain private health insurance, if and when it becmes available at a reasnable cst. Page 15 f 19
ENTAL The Party A I Party B (Circle One) shall be respnsible fr prviding dental insurance fr the minr child(ren): Thrugh Party A's I Party B's emplyment; OR By btaining and maintaining a private health insurance plicy; OR Thrugh current cverage under Mass Health. Either party shall btain private health insurance, if and when it becmes available at a reasnable cst. UNINSURE MEICAL AN ENTAL EXPENSES The cst f all reasnable uninsured and unreimbursed medical, dental, hspital, rthdntic, ptical, prescriptin medicatin and therapeutic cunseling services fr the minr child(ren) shall be as fllws: (Chse ONE f thefllwing). The first $250.00 per calendar year shall be paid by the custdial parent, wh is, Party A I Party B, with the remainder t be paid equally by the parties. Shared and paid equally by the parties. Paid as fllws: % by Party A, % by Party B. All uninsured medical, dental and pharmaceutical bills shall be presented by either within days f receipt f same. Each party shall reimburse his/her share f these csts t the ther within days frm the date when these bills are received frm the ther parent. isputes regarding unpaid bills shall be filed in the Prbate Curt within ne year f the date f treatment r cllectin shall be deemed waived. Neither parent shall cntract fr rthdntic treatment fr which the ther is respnsible withut prir written apprval frm the ther parent r further rder f the Curt. LIFE INSURANCE Party A shall maintain life insurance in the face amunt f: $, naming as the beneficiary, and shall be required t keep the life insurance in effect until ---------- Party B shall maintain life insurance in the face amunt f: $, naming -------------- as the - beneficiary, and shall be required t keep the life insurance in effect until ---------- Neither Party shall be required t maintain life insurance fr the benefit f the child(ren). Page 16 f 19
', TAX EPENANTS Party B shall claim the fllwing child(ren) as her dependant(s) fr state and federal incme tax purpses: Party A shall claim the fllwing child(ren) as his dependant(s) fr state and federal incme tax purpses: The Party A I Party B shall claim the child(ren) fr dd years. The Party A I Party B shall claim the child(ren) fr even years. The Parties shall alternate years in claiming the children as dependants fr state and federal incme tax purpses as fllws: --------------- The parties shall cperate with ne anther and the custdial parent shall sign all tax frms necessary t accmplish the tax prvisins set frth herein. EXHIBIT F - EUCATION Party A and Party B agree that each child shuld receive the best educatin available in light f his r her aptitudes and interests, including educatin at the cllege level. Party A and Party B, as he r she is financially able t d s, shall pay the cst f each child's educatinal expenses at such cllege, university r ther educatinal institutin a child(ren) may attend with the apprval f the parties, which apprval will nt be unreasnably withheld. As used in this exhibit, the term "educatinal expenses" shall include expenses in cnnectin with applying t cllege, including, but nt limited t applicatin fees, testing fees, as well as tuitin, bard, rm, bks, usual and custmary student activity fees and ther, expenses nrmally charged n bursar's bills, as well as reasnable transprtatin csts and ther csts agreed t by the Parties. Party A and Party B agree that they will cperate fully in seeking financial assistance fr cllege expenses, including schlarships, grants, student lans and the like, which may be available in rder t assist the parties in discharging this undertaking. Page 17 f 19
Party A and Party B agree that the chice f educatinal institutins fr a child shall be made after jint cnsultatin with due regard fr the financial circumstances f each party, and the aptitudes, interests and desires f the child. Neither party shall make any cmmitment t any educatinal institutin n behalf f the child withut first ntifying and btaining the ther party's written apprval, which apprval shall nt be unreasnably withheld. Neither parent shall cmmit t pst secndary educatin expenses fr which the ther shall be respnsible withut prir written apprval f the ther r further rder f the curt. EUCATION (additinal prvisins): INCORPORATION f this SCHEULE A int the SEPARATION AGREEMENT The parties sign and date this Schedule A in the same manner as their Separatin Agreement, t which it is attached, and the parties agree that the prvisins f this Schedule A shall be cnsidered t be fully incrprated int the Separatin Agreement and incrprated and merged int any Judgment f ivrce that may be entered by the Wrcester ivisin f the Prbate and Family Curt. Page 18 f 19
EXECUTION Signed n (ate) Party A 'ssignature Party A's PRINT NAME Signed n (ate) Party B's Signature Party B's PRINT NAME **************************************************************************** Cmmnwealth f Massachusetts Wrcester ivisin, ss. ate: ------------ Then persnally appeared the abve-named (Name) and acknwledged that HE I SHE signed the freging as HIS I HER free act and deed. My Cmmissin Expires:,Ntary Public Cmmnwealth f Massachusetts Wrcester ivisin, ss. ate: ------------ Then persnally appeared the abve-named (Name) and acknwledged that HE I SHE signed the freging as HIS I HER free act and deed. My Cmmissin Expires:,Ntary Public Page 19 f 19