===== PAGE 1 ===== # IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

Name	PLAINTIFF
vs.
Name	DEFENDANT 1
and (if applicable):
Name	DEFENDANT 2

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.

If you have children not addressed by this parenting plan, name here:

Child's INITIALS	Age	Where does the child live?
1. ________	______	______
2. ________	______	______
3. ________	______	______

===== PAGE 2 =====

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.)

===== PAGE 3 ===== Physical Custody (where the child/ren live): The child/ren’s residence is with: 广 Describe which days and which times of the day the child/ren will be with each person: Sunday: _____ Monday: _____ Tuesday: _____ Wednesday: ___ Thursday: ___ Friday: _____ Saturday: ___ Describe where and when the child/ren will be dropped off and/or picked up (day and time of day): Drop-Off: Where:_____ When: ___ Pick-Up: Where: ___ When: _____ ===== PAGE 4 =====

If there are any extraordinary costs (taxi, train, airplane, etc.), who will pay for which costs?

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

===== PAGE 5 ===== Child’s Birthday ___ ___ ___ ___ Mother’s Day ___ ___ ___ ___ Father’s Day ___ ___ ___ ___ Other ___ ___ ___ ___ Other ___ ___ ___ ___ Other ___ ___ ___ ___ Summer Schedule/ Vacation Plans: The quick brown fox jumps over the lazy dog.

Special Activities or School Activities:
Child’s Initials	List Activity	Both attend? If not, which parent attends?

===== PAGE 6 ===== 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

Generally, by what method may parents contact one another?

When the child/ren is/are with one of you, how may they contact the other parent?

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.)

===== PAGE 7 ===== 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