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IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
Name(ParentPlan)
| Name | PLAINTIFF |
|---|---|
| vs. | |
| Name | DEFENDANT 1 |
| and (if applicable): | |
| Name | DEFENDANT 2 |
Name_2(ParentPlan)
Name_3(ParentPlan)
CASE NO(ParentPlan)
CASE NO. _____
ACTION IN CUSTODY
PARENTING PLAN
This parenting plan involves the following child/children:
| Child's INITIALS | Age | Where does the child live? |
|---|---|---|
| 1. | ||
| 2. | ||
| 3. |
ChildInitials1(ParentPlan)
Age1(ParentPlan)
Childlive1(ParentPlan)
ChildInitials2(ParentPlan)
Age2(ParentPlan)
Childlive2(ParentPlan)
ChildInitials3(ParentPlan)
Age3(ParentPlan)
Childlive3(ParentPlan)
If you have children not addressed by this parenting plan, name here:
| Child's INITIALS | Age | Where does the child live? |
|---|---|---|
| 1. ________ | ______ | ______ |
| 2. ________ | ______ | ______ |
| 3. ________ | ______ | ______ |
ChildInitials4(ParentPlan)
Age4(ParentPlan)
Childlive4(ParentPlan)
ChildInitials5(ParentPlan)
Age5(ParentPlan)
Childlive5(ParentPlan)
ChildInitials6(ParentPlan)
Age6(ParentPlan)
Childlive6(ParentPlan)
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Legal Custody (who makes decisions about certain things):
| Check one | |||
| Diet | Both parties decide together | Plaintiff | Defendant |
|---|---|---|---|
| Religion | Both parties decide together | Plaintiff | Defendant |
| Medical Care | Both parties decide together | Plaintiff | Defendant |
| Mental Health Care | Both parties decide together | Plaintiff | Defendant |
| Discipline | Both parties decide together | Plaintiff | Defendant |
| Choice of School | Both parties decide together | Plaintiff | Defendant |
| Choice of Study | Both parties decide together | Plaintiff | Defendant |
| School Activities | Both parties decide together | Plaintiff | Defendant |
| Sports Activities | Both parties decide together | Plaintiff | Defendant |
| Additional Items | Both parties decide together | Plaintiff | Defendant |
| Explain the process you will use to make decisions:(For example, the parent confronted with or anticipating the choice will call the other parent when the choice presents itself, and the other parent must agree or disagree within 24 hours of any deadline.) | |||
Check Box2(ParentPlan)
Check Box3(ParentPlan)
Check Box1(ParentPlan)
Check Box4(ParentPlan)
Check Box5(ParentPlan)
Check Box6(ParentPlan)
Check Box7(ParentPlan)
Check Box8(ParentPlan)
Check Box9(ParentPlan)
Check Box10(ParentPlan)
Check Box11(ParentPlan)
Check Box12(ParentPlan)
Check Box14(ParentPlan)
Check Box15(ParentPlan)
Check Box13(ParentPlan)
Check Box17(ParentPlan)
Check Box16(ParentPlan)
Check Box18(ParentPlan)
Check Box20(ParentPlan)
Check Box21(ParentPlan)
Check Box19(ParentPlan)
Check Box24(ParentPlan)
Check Box22(ParentPlan)
Check Box23(ParentPlan)
Check Box25(ParentPlan)
Check Box26(ParentPlan)
Check Box27(ParentPlan)
Check Box28(ParentPlan)
Check Box29(ParentPlan)
Check Box30(ParentPlan)
Decisionprocess1(ParentPlan)
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Physical Custody (where the child/ren live):
The child/ren’s residence is with:
Physicalcustody(ParentPlan)
Describe which days and which times of the day the child/ren will be with each person:
Sunday: _____
Sunday(ParentPlan)
Monday: _____
Monday(ParentPlan)
Tuesday: _____
Tuesday(ParentPlan)
Wednesday: ___
Wednesday(ParentPlan)
Thursday: ___
Thursday(ParentPlan)
Friday: _____
Friday(ParentPlan)
Saturday: ___
Saturday(ParentPlan)
Describe where and when the child/ren will be dropped off and/or picked up (day and time of day):
Drop-Off:
Where:_____
Where1(ParentPlan)
When: ___
When1(ParentPlan)
Pick-Up:
Where: ___
Where_2(ParentPlan)
When: _____
When_2(ParentPlan)
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If one of you doesn't show up, how long will the other wait? ___
Howlong(ParentPlan)
If there are any extraordinary costs (taxi, train, airplane, etc.), who will pay for which costs?
Extraordinary(ParentPlan)
HOLIDAYS – Where will the child/children stay?
| HOLIDAYS – where will the child/children stay? | |||
| HOLIDAY | YEAR A | YEAR B | EVERY YEAR |
|---|---|---|---|
| Martin Luther King Day | |||
| Presidents Day | |||
| Easter | |||
| Memorial Day | |||
| Fourth of July | |||
| Labor Day | |||
| Yom Kippur | |||
| Rosh Hashanah | |||
| Thanksgiving | |||
| Vacation after Thanksgiving | |||
| Christmas Vacation | |||
| Kwanzaa | |||
| New Year’s Eve/Day | |||
| Spring Vacation | |||
| Easter Sunday | |||
YEAR A 1(ParentPlan)
YEAR B 1(ParentPlan)
EVERY YEAR 1(ParentPlan)
YEAR A 2(ParentPlan)
YEAR B 2(ParentPlan)
EVERY YEAR 2(ParentPlan)
YEAR A 3(ParentPlan)
YEAR B 3(ParentPlan)
EVERY YEAR 3(ParentPlan)
YEAR A 4(ParentPlan)
YEAR B 4(ParentPlan)
EVERY YEAR 4(ParentPlan)
YEAR A 5(ParentPlan)
YEAR B 5(ParentPlan)
EVERY YEAR 5(ParentPlan)
YEAR A 6(ParentPlan)
YEAR B 6(ParentPlan)
EVERY YEAR 6(ParentPlan)
YEAR A 7(ParentPlan)
YEAR B 7(ParentPlan)
EVERY YEAR 7(ParentPlan)
YEAR A 8(ParentPlan)
YEAR B 8(ParentPlan)
EVERY YEAR 8(ParentPlan)
YEAR A 9(ParentPlan)
YEAR B 9(ParentPlan)
EVERY YEAR 9(ParentPlan)
YEAR A 10(ParentPlan)
YEAR B 10(ParentPlan)
EVERY YEAR 10(ParentPlan)
YEAR A 11(ParentPlan)
YEAR B 11(ParentPlan)
EVERY YEAR 11(ParentPlan)
YEAR A 12(ParentPlan)
YEAR B 12(ParentPlan)
EVERY YEAR 12(ParentPlan)
YEAR A 13(ParentPlan)
YEAR B 13(ParentPlan)
EVERY YEAR 13(ParentPlan)
YEAR A 14(ParentPlan)
YEAR B 14(ParentPlan)
EVERY YEAR 14(ParentPlan)
YEAR A 15(ParentPlan)
YEAR B 15(ParentPlan)
EVERY YEAR 15(ParentPlan)
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Child’s Birthday ___ ___ ___ ___
Mother’s Day ___ ___ ___ ___
Father’s Day ___ ___ ___ ___
Other ___ ___ ___ ___
Other ___ ___ ___ ___
Other ___ ___ ___ ___
Summer Schedule/ Vacation Plans:
YEAR A 16(ParentPlan)
YEAR B 16(ParentPlan)
EVERY YEAR 16(ParentPlan)
YEAR A 17(ParentPlan)
YEAR B 17(ParentPlan)
EVERY YEAR 17(ParentPlan)
YEAR A 18(ParentPlan)
YEAR B 18(ParentPlan)
EVERY YEAR 18(ParentPlan)
YEAR A 19(ParentPlan)
YEAR B 19(ParentPlan)
EVERY YEAR 19(ParentPlan)
Other 1(ParentPlan)
Other 2(ParentPlan)
YEAR A 20(ParentPlan)
YEAR B 20(ParentPlan)
EVERY YEAR 20(ParentPlan)
Other 3(ParentPlan)
YEAR A 21(ParentPlan)
YEAR B 21(ParentPlan)
EVERY YEAR 21(ParentPlan)
The quick brown fox jumps over the lazy dog.
Summer Schedule/ Vacation Plans:
Special Activities or School Activities:
Child’s Initials List Activity Both attend? If not, which parent attends?
Summer(ParentPlan)
ChildInitials7(ParentPlan)
Activity 1(ParentPlan)
Attend1(ParentPlan)
ChildInitials8(ParentPlan)
Activity 2(ParentPlan)
Attend2(ParentPlan)
ChildInitials9(ParentPlan)
Activity 3(ParentPlan)
Attend3(ParentPlan)
ChildInitials10(ParentPlan)
Activity 4(ParentPlan)
Attend4(ParentPlan)
ChildInitials11(ParentPlan)
Activity 5(ParentPlan)
Attend5(ParentPlan)
ChildInitials12(ParentPlan)
Activity 6(ParentPlan)
Attend6(ParentPlan)
ChildInitials13(ParentPlan)
Activity 7(ParentPlan)
Attend7(ParentPlan)
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Temporary changes to this parenting schedule:
From time to time, one of you might want or need to rearrange the parenting time schedule due to work, family, or other events. You can attempt to agree on these changes. If you cannot agree, the parent receiving the request will make the final decision.
| The parent asking for the change will ask: (check all that apply) | ||||
| in person | by letter/mail | by phone | by email | by co-parenting app |
|---|---|---|---|---|
| No later than: | 12 hours | 24 hours | 1 week | 1 month ahead of time. |
| The parent being asked for a change will reply: (check all that apply) | ||||
| in person | by letter/mail | by phone | by email | by co-parenting app |
| No later than | 12 hours | 24 hours | 1 week | 1 month after being asked |
Check Box31(ParentPlan)
Check Box32(ParentPlan)
Check Box33(ParentPlan)
Check Box34(ParentPlan)
Check Box35(ParentPlan)
Check Box36(ParentPlan)
Check Box37(ParentPlan)
Check Box38(ParentPlan)
Check Box39(ParentPlan)
Check Box40(ParentPlan)
Check Box41(ParentPlan)
Check Box42(ParentPlan)
Check Box43(ParentPlan)
Check Box44(ParentPlan)
Check Box45(ParentPlan)
Check Box46(ParentPlan)
Check Box47(ParentPlan)
Check Box48(ParentPlan)
Generally, by what method may parents contact one another?
Contact(ParentPlan)
When the child/ren is/are with one of you, how may they contact the other parent?
Contact2(ParentPlan)
When and how may you contact the child when the child is with the other parent?
In the event that proposed changes, disputes or alleged breaches of this parenting plan and custody order are necessary or desired, the parties agree that such changes will be addressed by the following method (specify method, i.e., informal discussion, mediation, court action, etc.)
Contact3(ParentPlan)
Changes(ParentPlan)
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Other (Anything else you want to agree on):
| Date | Signature of Mother |
|---|---|
| Date | Signature of Father |
| Date | Signature of Mother’s Witness |
| Date | Signature of Father’s Witness |
Other 4(ParentPlan)
Date1(ParentPlan)
Date2(ParentPlan)
Date3(ParentPlan)
Date4(ParentPlan)