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COMMONWEALTH OF MASSACHUSETTS
THE TRIAL COURT
PROBATE AND FAMILY COURT DEPARTMENT
WORCESTER DIVISION _ DOCKET NO. _22D\So1
FILED
at fee Party A AUG - 5 2022
SMG.
and
Raliyah dape , Party B
SEPARATION AGREEMENT
This Agreement is made between:
Patty A: Wilts Lute Capo
. (name)
BY Greve Street Zak Flaov _ and
(address) ,
Party B: Aalpah Cape
, (aan)?
{address)
The parties were married in leominste Mea “on 66 (2H /20lF
(city, state) , O Gateh
and last lived together in "itehbure “me on / 2022
ity, state) 7 (date)
lof 16Children of the Marriage
. Choose 1, 2, or 3:
1. D1 There are no children born or adopted of this marriage;
2. C] There are no children born or adopted of this marriage under the age of 23 years old;
3. the children born or adopted of this marriage who are under the age of 23 years old are:
+ Asmata. Kar tt date of bith oY /Z0/ 90/9
(child's first middle and last
date of birth
date of birth
date of birth
date of birth
This Separation Agreement is made in order to settle and determine:
a) the property and support rights and obligations of the parties; and
) the care, custody, support, maintenance and education of the minor and/or dependent child(ren)
of the marriage (see schedule A); and
b) all other rights and obligations arising from the marriage.
SECTION ONE: PROPERTY DIVISION AND DEBTS
A) MARITAL HOME (the shared residence during the marriage, regardless of how title is held)
Choose 1 or 2;
1. J4 Neither party holds any interest in real estate, either jointly or individually.
2.01 One, or both of the parties, owns the martial home
Name(s) on deed:
Martial Home Address:
1. Selling the Marital Home
Choose I or 2:
1. Ol The parties have already divided their interest in the marital home as follows:
2 of 162. OO The parties agree to have the marital home listed for sale by:
: (date)
The net proceeds or debts of the sale shall be divided as follows:
Until the sale, the expenses of the marital home shall be paid as follows:
2. Keeping the Marital Home
Choose J, 2 or 3:
1.0 owns the marital home in his/her individual name and shall
(came)
continue to be the owner after the divorce.
2.0 The mortgage on the marital home shall be refinanced by
(name)
onor before
, Gate)
In the event that the party is unable to refinance, then the parties shall:
3. C1 Other agreement for the marital home:
B) OTHER REAL ESTATE (if either party owns other real estate, a separate page must be attached
answering the same questions in section 1 and 2 of the martial home)
Choose | or 2: . /
1. (1 One or both of the parties has other real estate and additional pages are attached, signed
and dated, which shall be part of this Agreement.
2. A Neier of parties has other real estate.
3 of 16©) PERSONAL PROPERTY (includes vehicles, farniture, household items, etc., but excludes banks,
_ ivestments and retirement accounts)
Choose 1, 2 or 34/3B:
1. O There has been a full and satisfactory division of all personal property and each party
shall have full right, title and interest in all items of personal property now in their respective
possession.
2. C1 The parties agree they will exchange the following items of personal property (detail
every item and the date by which the item(s) are to be retrieved):
If the items are not retdeved by the date specified that party hereby waives all ght, tle
and interest in the personal property. A
3A.1]_____shall have fill ight, tile and interest in the following :
(name)
Property:
38.0 shall have full right, title and interest in the following
(azms)
Property:
provisions, if applicable
1 Each party shal! retain the motor vehicle(s) in their name and any loan associated with it
2.0 . will retain and refinance to
(name). (year, make and model)
temove the other party from the associated debt by :
(date)
4 of 16VEE D)'BANK ACCOUNTS
1. Individual accounts:
1 Each party shall have full right, title and interest in the bank accounts listed on their financial
statements.
Exception, if applicable: shall pay $ to
- (name)
the other party by from his/her individual account.
(cate)
2. Joint accounts:
Choose 1 or 2:
1A The parties have no joint bank accounts.
2. O The parties have closed all joint accounts and divided the funds.
E) PENSION RETIREMENT BENEFIT (this includes pension, 401K, IRA, etc.)
Choose 1, 2 gr3:
Neither of the parties have a retirement account of any kind.
2. C1 One or both of the parties have a retirement account as listed on their financial statement
and agree as follows (choose A or B):
. A. 01 The parties shall each keep their respective retirements benefits listed in their
financial statements and the other party waives all right, title and interest in the
other party's retirement account(s).
B.O shall transfer (dollar amount
(oame)
or percentage) account to the other party of as
(name of financial institutioa)
plus/minus any gains or losses at the time of transfer.
(Gate)
The parties shall cooperate with one another to prepare any and all necessary documents
for the transfer including preparing a Qualified Domestic Relations Order if necessary.
The costs of preparation and all other ‘expenses associated with this transfer shall be
paid by OR equally.
(ame of party)
3. D Other:
5 of 16F/) OTHER INVESTMENTS/INTANGIBLE PROPERTY (stocks, bonds, business interests, etc.)
* Choose 1,2, oy 3:
1. yi Neither party holds any interest in intangible property/other investments
2. Each party shall keep any and all intangible property/other investments in their individual
name.
3.0 shall have full right, title and interest in the following:
(name of party)
G) DEBTS
Choose J or 2:
1 A Each party shall be responsible for all debt lists in his/her individual name as listed on
his/her financial statement.
2. O The martial debt of the parties shall be paid as follows (list creditor, amount owed and division
between the parties):
SECTION TWO: ALIMONY
Choose I, 2 op:
1,4] Each party hereby waives past, present and future alimony.
2.) Each party waives past and present alimony but both parties reserve the right to future
alimony.
3.0 : . shall pay alimony to the other party. Alimony shall be in the
(name)
amount of $ every week/month, beginning - Payments of
alimony shail end (choose one):
© On the date of
O When the following event(s) occur:
O Pursuant to Massachusetts Law
O Other
6 of 16SECTION THREE: LIFE INSURANCE
” Choose 1 or 2: - .
. 1,41 Neither party shall be required to maintain life insurance for the benefit of the other.
2.0 shall maintain $ of life insurance for the other's
{name of one party)
benefit until _-
SECTION FOUR: HEALTH CARE
1. Health Care Coverage
Choose J or 27
1.14 Each party shall be responsible for obtaining and paying their own health insurance upon the
Divorce izing.
2.0 : ‘shall continue to provide health insurance for the other party. If
" (aame) :
there is an additional cost for the continued coverage, that cost shall be paid by
with payment due on or before
(name)
2. Uninsured Medical Expenses (this includes costs not fully covered by insurance such as e0-pays, ,
deductibles, counseling, dental, optical, hospital, prescription medications, etc.)
Choose I or 2:
1 fa fach party shall be responsible for their own health, dental and vision costs not covered by
2.0 Other:
SECTION FIVE: INCOME TAXES
Choose 1} or 2: .
1. C1 The parties shall file separate federal and state taxes for the tax year
and beyond.
2. U1 The parties shall file joint federal and state tax returns for the tax year and
share any refund received, tax due and tax preparation fee as follows:
7 of 16. SECTION SEX: FORMER NAME
A; hy Layo seeks to resume the former name of Auiyt Kida
GOVERNING LAW
This Separation Agreement shall be construed and governed according to the laws of the Commonwealth
of Massachusetts.
FULL DISCLOSURE OF INCOME, ASSETS AND LIABILITIES
The parties hereby represent that they have each made full disclosure to the other party of their individual
income, assets and liabilities. Each party represents that they have provided the other party with a current
financial statement which discloses fully and completely all of the party's income, expenses, assets and
liabilities. By executing this Separation Agreement, the parties represent that the terms and provisions of
this agreement are fair, just and reasonable and are not the product of fraud, coercion or undue influence
and that each signs this agreement freely and voluntarily.
8 of 16SECTION SEVEN: STATUS OF THE AGREEMENT
The parties need to agree upon the specific provisions, if any, that may be modified in the future.
Read all options and choose 1, 2 or 3
1. N MERGER: This Separation Agreement shall be incorporated and merged into the
Divorce Judgment and shall not survive as an independent contract. We agree therefore
that all provisions in this agreement may be modified in the future, except for property
division and liabilities. :
2. O SURVIVAL: This Separation Agreement shall be incorporated but not merged
into the Divorce Judgment, and shall survive as an independent contract. We agree
therefore that all provisions in this agreement may not be modified in the future.
3. FL) SURVIVAL EXCEPTIONS: This Sepafation Agreement shall be incorporated
but nor merged into the Divorce Judgment, and shall survive as an independent contract,
except for the following terms and provisions which shall merge. We agree therefore
that only the following provisions may be modified in the future:
Choose a as many as apply:
. O Alimony
6 Life Insurance
O Health Insurance
O Income Taxes
O Child Related-Matters
9 of 16SCHEDULE A: CHILD RELATED MATTERS
1. LEGAL CUSTODY (which parent or parents makes major decisions for the child(ren) for health care,
religion, education etc.)
Choose 1 or 2:
1. 0 The parties shall have shared legal custody of the minor child(ren).
2 W thh ‘S ! ufe apoB have sole legal c tstody of the child(ren).
(name)
2. PHYSICAL CUSTODY (primary residence of the child(ren) and day-to-day decisions regarding the ~
child(ren).
Choose 1, 2, 3 or 4:
1. C1 The patties shall have shared physical custody of the minor child(ren) in accordance with the
parenting schedule specified below in number 3.
2. hi 1 {U8 Lute l Zap Tai have sole physical custody of the child(ren).
(name)
3. OA The parties will have shared 4 physical custody of the children as follows:
wy, UK j shall have sole physical custody of the
(name) .
following stileen): Asada Kas Gago
4. (0 Other
3. PARENTING SCHEDULE
The parties may agree to parenting time other than set forth below; however, in the event the parties
cannot agree, the terms of this agreement shall apply.
A. Regular Schedule (this is the regular weeldy schedule between the parties. Include days and times for
each parent so that all hours are accounted for)
Choose I, 2, 3or 4
1. a The parties agree that they do not need a written schedule.
2. the non-custodial parent Aly h Lape shall have the child(ren) during the
(name)
10 of 16* Stas arr} hat — 5 fry)
3. M the its share physical custody and the schedule shall be as follows:
‘hild(ren) shall be with _ during the following days
__{name pf one parent)
and times: Mardy = Friday
PW Critaren) shall be with Aale Jah LZ BD during the following days
(name.of one parent) *
and times: -
L Gd Ana —S Py
us ao?
4. O1 Other regular parenting time provisions:
B. Exceptions to the Regular Parenting Schedule (these exceptions have priority over the regular
parenting schedule, List the party who has the child(ren )during the specified time and whether the parties
are alternating years)
Complete all that are applicable.
OY ttotiaays (For example: so Mother's Day, Father's Day, Thanksgiving, Christmas, etc.):
Ligihobss Day
ue
yt Capp : \
f) LA
i
a 7 a7 yeas
School Vacations (Dee: “Ac lig break, February break, April/spring break, summer, etc.):
Qummee — Lah Lay wD
11 of 16™
Any changes to the regular parenting plan or the holiday/vacation schedule shall be mutually
arranged between the parties with jap days advance notice.
C. Transportation
Choose 1, 2 or 3:
1. 1 When parenting time begins for one parent, that parent shall pick up the child(ren) or
arrange for other reasonable transportation.
2. When parenting time ends for one parent, that parent shall drop off the child(ren) or
arrange for other reasonable transportation :
3.{1 The pick-up and drop-off plan is as follows:
4. CHILD SUPPORT
A. Payment-of Child Support
Choose I or 2:
1.00 Beginning > shall pay child support to
(date) (name of payor) .
the other party in the amount of $ each and every week / two weeks / month
__ (Circle one)
O Payment shall be made (choose one):
O Direct to the other party by
(check, direct deposit, etc)
O by wage assignment through the Department of Revenue.
2. A Neitner party shall pay child support to the other for the following reasons:
Ye can not aftord te te with tern come she se
gethhy ‘
12 of 16o The parties acknowledge that the child support order which would result from the application © of the
Child Support Guidelines is $ per week.
B. Termination of Child Support
Choose I or 2:
1.1 Pursuant to the Massachusetts Law:
The court may make appropriate orders of maintenance, support and education of any
child who has attained age eighteen but who has not attained age twenty-one and who is
domiciled in the home of a parent, and is principally dependent upon said parent for
maintenance; who has attained age twenty-one but who has not attained age twenty-
three, if such child is domiciled in the home of a parent, and is principally dependent
upon said parent for maintenance due to the enroliment of such child in an educational
program, excluding educational costs beyond an undergraduate degree.
2.10 Other
5. HEALTH AND DENTAL COVERAGE FOR CHILD(REN)
A. Health Insurance
Qa. hiyah dago shall be responsible for providing health insurance for
(name)
the minor child(ren) through (choose ome):
O Their employer OR
O By obtaining and maintaining a private health insurance policy OR °
JAI Through current coverage under MassHealth. Either party shall obtain private health
insurance, if and when it becomes available. .
B. Dental Insurance, if available
Me Higa A ca eo: shall be responsible for providing dental insurance for
(name;
the minor child(ren) through (choose one):
O Their employer OR
0 By obtaining and maintaining a private insurance policy OR .
J Through current coverage under MassHealth. Either party shall obtain private health
insurance, if and when it becomes available.
C. Uninsured Medical and Dental Expenses
The cost of all reasonable and necessary uninsured and unreimbursed medical and dental expenses for the
minor child(ren) shall be paid as follows:
Choose I, 2 or 3 and 4, if applicable:
1. C1 The first $250 per calendar year shall be paid by the custodial parent with the
remainder to be paid equally by the parties.
13 of 162. O Paid equally between the parties, written proof of invoice and paid receipt to be
provided promptly.
3. 1 Other:
4, C1 Neither party shall incur an expense over $ without the
other party's written consent.
6. LIFE INSURANCE
Choose 1 or Be .
L ‘Neither party shall be required to maintain life insurance for the benefit of the child(ren).
24.0] shall maintain life insurance in the face amount of
(name) :
$ naming -_as the beneficiary as long as
there is a child support obligation.
238.0 shall maintain life insurance in the face amount of
(name)
$ naming as the beneficiary as long as
there is a child support obligation.
7. COLLEGE EXPENSES
Choose 1, 2 oy3: :
1. id The parties make no provisions regarding college at this time and agree to discuss at the
time the child(ren) is applying. .
2. Cl The parties agree as follows:
3. A the parties agree that they will consult with one another, together with the child, as to the
selection of a college. Neither party shall commit the other to any financial obligation for college
without the other party's written authorization or written consent. Neither party shall be financially
responsible for the cost of college arising from the other party's action as to the college selection
for a child.
14 of 168. TAX DEPENDENTS
The parties acknowledge that there has been a recent change in the tax code and the impact of any
agreement made relative to claiming a tax dependent may not be applicable; nonetheless the parties agree
as follows:
4A Ls (20 shall claim the following child(ren):
(oie) :
a O€ (21 a OS BOfZAE for
. (name and daté of Birth of child(ren))
~ income tax-purposes (choose one):
Every tax year
O Every even-number tax year, beginning tax year
O Every odd-number tax year begging with tax year
c
O shall claim the following child(ren):
(other parent's name) .
’ for
(name and date of birth of child(ren))
income tax purposes (choose one):
O Every tax year
C1 Every even-number tax year, beginning tax year
(1 Every odd-number tax year begging with tax year
CO] Other
15 of 16$729 Laces
Dfte Signed
3/: AD [yoag
Date Signed
On this ag
EXECUTION
Li Lele Abbe boo
Signature of Party
holis Latte CapoTi
Print Name
NOTARIZATION
Commonwealth of Massachusetts
day of Jeud , 20 “before me, the
undersigned (4) «(7 Lo apa : Ce personally appeared before me and
proved to me through / satisfactory evidence of identification, which was
MA Drivers Licence
» to be the person whose name is signed on-the
preceding or attached document in my presence.
§\_ JOANNA BILOTTA-SIMEONE
% Notary Public
COMMONWEALTH OF MASSACHUSETTS.
My Commission Expires
January 13, 2023
Oho. Ly (th- sulne oR
(()Pkieial signature and seal of NO
My comes, expires onlay Sheicert 4 1372033
Commonwealth of Massachusetts
On this 2g day of TL. » 20 2 , before me, the
undersigned AAA]; yah lap? f personally appeared before me and
proved _to me ‘through satisfactory evidence of identification, which was
WA Peters Licence
preceding or attached document in my presence.
, to be the person whose name is signed on the
16 of 16
Preview
COMMONWEALTH OF MASSACHUSETTS THE TRIAL COURT PROBATE AND FAMILY COURT DEPARTMENT WORCESTER DIVISION _ DOCKET NO. _22D\So1 FILED at fee Party A AUG - 5 2022 SMG. and Raliyah dape , Party B SEPARATION AGREEMENT This Agreement is made between: Patty A: Wilts Lute Capo . (name) BY Greve Street Zak Flaov _ and (address) , Party B: Aalpah Cape , (aan)? {address) The parties were married in leominste Mea “on 66 (2H /20lF (city, state) , O Gateh and last lived together in "itehbure “me on / 2022 ity, state) 7 (date) lof 16Children of the Marriage . Choose 1, 2, or 3: 1. D1 There are no children born or adopted of this marriage; 2. C] There are no children born or adopted of this marriage under the age of 23 years old; 3. the children born or adopted of this marriage who are under the age of 23 years old are: + Asmata. Kar tt date of bith oY /Z0/ 90/9 (child's first middle and last date of birth date of birth date of birth date of birth This Separation Agreement is made in order to settle and determine: a) the property and support rights and obligations of the parties; and ) the care, custody, support, maintenance and education of the minor and/or dependent child(ren) of the marriage (see schedule A); and b) all other rights and obligations arising from the marriage. SECTION ONE: PROPERTY DIVISION AND DEBTS A) MARITAL HOME (the shared residence during the marriage, regardless of how title is held) Choose 1 or 2; 1. J4 Neither party holds any interest in real estate, either jointly or individually. 2.01 One, or both of the parties, owns the martial home Name(s) on deed: Martial Home Address: 1. Selling the Marital Home Choose I or 2: 1. Ol The parties have already divided their interest in the marital home as follows: 2 of 162. OO The parties agree to have the marital home listed for sale by: : (date) The net proceeds or debts of the sale shall be divided as follows: Until the sale, the expenses of the marital home shall be paid as follows: 2. Keeping the Marital Home Choose J, 2 or 3: 1.0 owns the marital home in his/her individual name and shall (came) continue to be the owner after the divorce. 2.0 The mortgage on the marital home shall be refinanced by (name) onor before , Gate) In the event that the party is unable to refinance, then the parties shall: 3. C1 Other agreement for the marital home: B) OTHER REAL ESTATE (if either party owns other real estate, a separate page must be attached answering the same questions in section 1 and 2 of the martial home) Choose | or 2: . / 1. (1 One or both of the parties has other real estate and additional pages are attached, signed and dated, which shall be part of this Agreement. 2. A Neier of parties has other real estate. 3 of 16©) PERSONAL PROPERTY (includes vehicles, farniture, household items, etc., but excludes banks, _ ivestments and retirement accounts) Choose 1, 2 or 34/3B: 1. O There has been a full and satisfactory division of all personal property and each party shall have full right, title and interest in all items of personal property now in their respective possession. 2. C1 The parties agree they will exchange the following items of personal property (detail every item and the date by which the item(s) are to be retrieved): If the items are not retdeved by the date specified that party hereby waives all ght, tle and interest in the personal property. A 3A.1]_____shall have fill ight, tile and interest in the following : (name) Property: 38.0 shall have full right, title and interest in the following (azms) Property: provisions, if applicable 1 Each party shal! retain the motor vehicle(s) in their name and any loan associated with it 2.0 . will retain and refinance to (name). (year, make and model) temove the other party from the associated debt by : (date) 4 of 16VEE D)'BANK ACCOUNTS 1. Individual accounts: 1 Each party shall have full right, title and interest in the bank accounts listed on their financial statements. Exception, if applicable: shall pay $ to - (name) the other party by from his/her individual account. (cate) 2. Joint accounts: Choose 1 or 2: 1A The parties have no joint bank accounts. 2. O The parties have closed all joint accounts and divided the funds. E) PENSION RETIREMENT BENEFIT (this includes pension, 401K, IRA, etc.) Choose 1, 2 gr3: Neither of the parties have a retirement account of any kind. 2. C1 One or both of the parties have a retirement account as listed on their financial statement and agree as follows (choose A or B): . A. 01 The parties shall each keep their respective retirements benefits listed in their financial statements and the other party waives all right, title and interest in the other party's retirement account(s). B.O shall transfer (dollar amount (oame) or percentage) account to the other party of as (name of financial institutioa) plus/minus any gains or losses at the time of transfer. (Gate) The parties shall cooperate with one another to prepare any and all necessary documents for the transfer including preparing a Qualified Domestic Relations Order if necessary. The costs of preparation and all other ‘expenses associated with this transfer shall be paid by OR equally. (ame of party) 3. D Other: 5 of 16F/) OTHER INVESTMENTS/INTANGIBLE PROPERTY (stocks, bonds, business interests, etc.) * Choose 1,2, oy 3: 1. yi Neither party holds any interest in intangible property/other investments 2. Each party shall keep any and all intangible property/other investments in their individual name. 3.0 shall have full right, title and interest in the following: (name of party) G) DEBTS Choose J or 2: 1 A Each party shall be responsible for all debt lists in his/her individual name as listed on his/her financial statement. 2. O The martial debt of the parties shall be paid as follows (list creditor, amount owed and division between the parties): SECTION TWO: ALIMONY Choose I, 2 op: 1,4] Each party hereby waives past, present and future alimony. 2.) Each party waives past and present alimony but both parties reserve the right to future alimony. 3.0 : . shall pay alimony to the other party. Alimony shall be in the (name) amount of $ every week/month, beginning - Payments of alimony shail end (choose one): © On the date of O When the following event(s) occur: O Pursuant to Massachusetts Law O Other 6 of 16SECTION THREE: LIFE INSURANCE ” Choose 1 or 2: - . . 1,41 Neither party shall be required to maintain life insurance for the benefit of the other. 2.0 shall maintain $ of life insurance for the other's {name of one party) benefit until _- SECTION FOUR: HEALTH CARE 1. Health Care Coverage Choose J or 27 1.14 Each party shall be responsible for obtaining and paying their own health insurance upon the Divorce izing. 2.0 : ‘shall continue to provide health insurance for the other party. If " (aame) : there is an additional cost for the continued coverage, that cost shall be paid by with payment due on or before (name) 2. Uninsured Medical Expenses (this includes costs not fully covered by insurance such as e0-pays, , deductibles, counseling, dental, optical, hospital, prescription medications, etc.) Choose I or 2: 1 fa fach party shall be responsible for their own health, dental and vision costs not covered by 2.0 Other: SECTION FIVE: INCOME TAXES Choose 1} or 2: . 1. C1 The parties shall file separate federal and state taxes for the tax year and beyond. 2. U1 The parties shall file joint federal and state tax returns for the tax year and share any refund received, tax due and tax preparation fee as follows: 7 of 16. SECTION SEX: FORMER NAME A; hy Layo seeks to resume the former name of Auiyt Kida GOVERNING LAW This Separation Agreement shall be construed and governed according to the laws of the Commonwealth of Massachusetts. FULL DISCLOSURE OF INCOME, ASSETS AND LIABILITIES The parties hereby represent that they have each made full disclosure to the other party of their individual income, assets and liabilities. Each party represents that they have provided the other party with a current financial statement which discloses fully and completely all of the party's income, expenses, assets and liabilities. By executing this Separation Agreement, the parties represent that the terms and provisions of this agreement are fair, just and reasonable and are not the product of fraud, coercion or undue influence and that each signs this agreement freely and voluntarily. 8 of 16SECTION SEVEN: STATUS OF THE AGREEMENT The parties need to agree upon the specific provisions, if any, that may be modified in the future. Read all options and choose 1, 2 or 3 1. N MERGER: This Separation Agreement shall be incorporated and merged into the Divorce Judgment and shall not survive as an independent contract. We agree therefore that all provisions in this agreement may be modified in the future, except for property division and liabilities. : 2. O SURVIVAL: This Separation Agreement shall be incorporated but not merged into the Divorce Judgment, and shall survive as an independent contract. We agree therefore that all provisions in this agreement may not be modified in the future. 3. FL) SURVIVAL EXCEPTIONS: This Sepafation Agreement shall be incorporated but nor merged into the Divorce Judgment, and shall survive as an independent contract, except for the following terms and provisions which shall merge. We agree therefore that only the following provisions may be modified in the future: Choose a as many as apply: . O Alimony 6 Life Insurance O Health Insurance O Income Taxes O Child Related-Matters 9 of 16SCHEDULE A: CHILD RELATED MATTERS 1. LEGAL CUSTODY (which parent or parents makes major decisions for the child(ren) for health care, religion, education etc.) Choose 1 or 2: 1. 0 The parties shall have shared legal custody of the minor child(ren). 2 W thh ‘S ! ufe apoB have sole legal c tstody of the child(ren). (name) 2. PHYSICAL CUSTODY (primary residence of the child(ren) and day-to-day decisions regarding the ~ child(ren). Choose 1, 2, 3 or 4: 1. C1 The patties shall have shared physical custody of the minor child(ren) in accordance with the parenting schedule specified below in number 3. 2. hi 1 {U8 Lute l Zap Tai have sole physical custody of the child(ren). (name) 3. OA The parties will have shared 4 physical custody of the children as follows: wy, UK j shall have sole physical custody of the (name) . following stileen): Asada Kas Gago 4. (0 Other 3. PARENTING SCHEDULE The parties may agree to parenting time other than set forth below; however, in the event the parties cannot agree, the terms of this agreement shall apply. A. Regular Schedule (this is the regular weeldy schedule between the parties. Include days and times for each parent so that all hours are accounted for) Choose I, 2, 3or 4 1. a The parties agree that they do not need a written schedule. 2. the non-custodial parent Aly h Lape shall have the child(ren) during the (name) 10 of 16* Stas arr} hat — 5 fry) 3. M the its share physical custody and the schedule shall be as follows: ‘hild(ren) shall be with _ during the following days __{name pf one parent) and times: Mardy = Friday PW Critaren) shall be with Aale Jah LZ BD during the following days (name.of one parent) * and times: - L Gd Ana —S Py us ao? 4. O1 Other regular parenting time provisions: B. Exceptions to the Regular Parenting Schedule (these exceptions have priority over the regular parenting schedule, List the party who has the child(ren )during the specified time and whether the parties are alternating years) Complete all that are applicable. OY ttotiaays (For example: so Mother's Day, Father's Day, Thanksgiving, Christmas, etc.): Ligihobss Day ue yt Capp : \ f) LA i a 7 a7 yeas School Vacations (Dee: “Ac lig break, February break, April/spring break, summer, etc.): Qummee — Lah Lay wD 11 of 16™ Any changes to the regular parenting plan or the holiday/vacation schedule shall be mutually arranged between the parties with jap days advance notice. C. Transportation Choose 1, 2 or 3: 1. 1 When parenting time begins for one parent, that parent shall pick up the child(ren) or arrange for other reasonable transportation. 2. When parenting time ends for one parent, that parent shall drop off the child(ren) or arrange for other reasonable transportation : 3.{1 The pick-up and drop-off plan is as follows: 4. CHILD SUPPORT A. Payment-of Child Support Choose I or 2: 1.00 Beginning > shall pay child support to (date) (name of payor) . the other party in the amount of $ each and every week / two weeks / month __ (Circle one) O Payment shall be made (choose one): O Direct to the other party by (check, direct deposit, etc) O by wage assignment through the Department of Revenue. 2. A Neitner party shall pay child support to the other for the following reasons: Ye can not aftord te te with tern come she se gethhy ‘ 12 of 16o The parties acknowledge that the child support order which would result from the application © of the Child Support Guidelines is $ per week. B. Termination of Child Support Choose I or 2: 1.1 Pursuant to the Massachusetts Law: The court may make appropriate orders of maintenance, support and education of any child who has attained age eighteen but who has not attained age twenty-one and who is domiciled in the home of a parent, and is principally dependent upon said parent for maintenance; who has attained age twenty-one but who has not attained age twenty- three, if such child is domiciled in the home of a parent, and is principally dependent upon said parent for maintenance due to the enroliment of such child in an educational program, excluding educational costs beyond an undergraduate degree. 2.10 Other 5. HEALTH AND DENTAL COVERAGE FOR CHILD(REN) A. Health Insurance Qa. hiyah dago shall be responsible for providing health insurance for (name) the minor child(ren) through (choose ome): O Their employer OR O By obtaining and maintaining a private health insurance policy OR ° JAI Through current coverage under MassHealth. Either party shall obtain private health insurance, if and when it becomes available. . B. Dental Insurance, if available Me Higa A ca eo: shall be responsible for providing dental insurance for (name; the minor child(ren) through (choose one): O Their employer OR 0 By obtaining and maintaining a private insurance policy OR . J Through current coverage under MassHealth. Either party shall obtain private health insurance, if and when it becomes available. C. Uninsured Medical and Dental Expenses The cost of all reasonable and necessary uninsured and unreimbursed medical and dental expenses for the minor child(ren) shall be paid as follows: Choose I, 2 or 3 and 4, if applicable: 1. C1 The first $250 per calendar year shall be paid by the custodial parent with the remainder to be paid equally by the parties. 13 of 162. O Paid equally between the parties, written proof of invoice and paid receipt to be provided promptly. 3. 1 Other: 4, C1 Neither party shall incur an expense over $ without the other party's written consent. 6. LIFE INSURANCE Choose 1 or Be . L ‘Neither party shall be required to maintain life insurance for the benefit of the child(ren). 24.0] shall maintain life insurance in the face amount of (name) : $ naming -_as the beneficiary as long as there is a child support obligation. 238.0 shall maintain life insurance in the face amount of (name) $ naming as the beneficiary as long as there is a child support obligation. 7. COLLEGE EXPENSES Choose 1, 2 oy3: : 1. id The parties make no provisions regarding college at this time and agree to discuss at the time the child(ren) is applying. . 2. Cl The parties agree as follows: 3. A the parties agree that they will consult with one another, together with the child, as to the selection of a college. Neither party shall commit the other to any financial obligation for college without the other party's written authorization or written consent. Neither party shall be financially responsible for the cost of college arising from the other party's action as to the college selection for a child. 14 of 168. TAX DEPENDENTS The parties acknowledge that there has been a recent change in the tax code and the impact of any agreement made relative to claiming a tax dependent may not be applicable; nonetheless the parties agree as follows: 4A Ls (20 shall claim the following child(ren): (oie) : a O€ (21 a OS BOfZAE for . (name and daté of Birth of child(ren)) ~ income tax-purposes (choose one): Every tax year O Every even-number tax year, beginning tax year O Every odd-number tax year begging with tax year c O shall claim the following child(ren): (other parent's name) . ’ for (name and date of birth of child(ren)) income tax purposes (choose one): O Every tax year C1 Every even-number tax year, beginning tax year (1 Every odd-number tax year begging with tax year CO] Other 15 of 16$729 Laces Dfte Signed 3/: AD [yoag Date Signed On this ag EXECUTION Li Lele Abbe boo Signature of Party holis Latte CapoTi Print Name NOTARIZATION Commonwealth of Massachusetts day of Jeud , 20 “before me, the undersigned (4) «(7 Lo apa : Ce personally appeared before me and proved to me through / satisfactory evidence of identification, which was MA Drivers Licence » to be the person whose name is signed on-the preceding or attached document in my presence. §\_ JOANNA BILOTTA-SIMEONE % Notary Public COMMONWEALTH OF MASSACHUSETTS. My Commission Expires January 13, 2023 Oho. Ly (th- sulne oR (()Pkieial signature and seal of NO My comes, expires onlay Sheicert 4 1372033 Commonwealth of Massachusetts On this 2g day of TL. » 20 2 , before me, the undersigned AAA]; yah lap? f personally appeared before me and proved _to me ‘through satisfactory evidence of identification, which was WA Peters Licence preceding or attached document in my presence. , to be the person whose name is signed on the 16 of 16