KY-DO-10A
INSTRUCTIONS
When should this form be used?
This form should be used when the parties desire to enter into a Separation Agreement to be
effective immediately. This form is for married persons with children without joint
property or debts. This form is for the State of Kentucky.
This form should be completed on your computer, typed or printed in black ink. Both parties
must sign the Agreement and have their signatures witnessed by a notary public . You may
desire to print and sign duplicate originals so that both parties will have a signed original of the
document.
Transfers of Title to Property
This form may not be sufficient to transfer title to property such as real estate, automobiles and
other property to be divided. These transfers must be done by a deed, bill of sale, title or other
instruction before the ownership is final.
Opportunity to Consult with Attorney
This Agreement provides that you were given an opportunity to consult with an attorney of your
choice prior to execution of the Agreement.
Divorce Proceeding
This form provides that the parties intend to be bound by this Agreement as a contract between
the parties regardless of whether a divorce action is filed. Certain conduct may invalidate the
Agreement such as cohabitation and sexual relations with each other after signing the
Agreement. If a divorce action is filed, the Court may or may not be bound by all provisions
contained in the Agreement. For example, Courts generally have the final say about child
custody, child support, alimony and other like matters.
MARITAL SEPARATION AND PROPERTY SETTLEMENT AGREEMENT
WITH DEPENDENT MINOR CHILD(REN)
NOTICE: THIS IS AN IMPORTANT LEGAL AGREEMENT AND HAS
SUBSTANTIAL LEGAL CONSEQUENCES ON YOU, YOUR RIGHTS AND
OBLIGATIONS. YOU ARE ADVISED TO CONSULT AN ATTORNEY FOR
INDEPENDENT LEGAL ADVICE PRIOR TO EXECUTION OF THIS AGREEMENT.
STATE OF KENTUCKY
COUNTY OF _________________
WHEREAS, ____________________________________ (full legal name), hereinafter
referred to as "Wife", and _________________________________ (full legal name),
hereinafter referred to as "Husband", are now married, having been married on the _____
day of ____________, _______, in ______________ County, _________________; and
WHEREAS, the parties were separated on or about the _______ day of
_______________, 20___, while residing in _______________ County,
_________________, and since that date have been living separate and apart; and
WHEREAS, differences between the parties have arisen which have resulted in an
irretrievable breakdown of the marriage and there is no chance of staying together. The
parties make this Agreement to settle once and for all that the parties owe to each other
and what the parties can expect to receive from each other; and
WHEREAS, the parties desire to make a mutually acceptable settlement of their rights,
liabilities, obligations and property rights arising out of and during the course of their
marital relationship. No reconciliation is contemplated; and
WHEREAS, the parties agree to execute and exchange any papers that might be needed
to complete this Agreement, including deeds, title certificates, bills of sale, etc.; and
Husband Initials:___________ Wife Initials: ___________
WHEREAS, the parties intend that this Agreement shall be binding on them from and
after the date and time of execution, if permitted, and that this Agreement may be
incorporated into a final judgment of divorce at some future time.
NOW THEREFORE, FOR AND IN CONSIDERATION of the mutual benefits and
advantages accruing to each party, the undersigned do hereby solemnly covenant, agree
and contract as set forth above and below and being sworn, certify that the all statements
contained herein are true and correct:
SECTION 1.
SEPARATION; RELINQUISHMENT OF MARITAL RIGHTS
The parties shall continue to live separate and apart, free from interference, authority and
control by the other, as if each were sole and unmarried, and each may conduct, carry on
and engage in any employment, business or trade which each shall seem advisable for
their sole and separate use and benefit, without, and free from any control, restraint or
interference by the other party in all respects as if each were unmarried. Neither of the
parties shall molest or annoy the other or seek to compel the other to cohabit or dwell
with the other by any proceedings for restoration of conjugal rights or otherwise, or exert
or demand any right to reside in the home of the other, if any.
SECTION 2.
FINANCIAL DISCLOSURES
By execution of this instrument, each party warrants and represents to the other party
that he or she has fully disclosed their financial status, including their assets and
liabilities of all types and agree that the terms of this Agreement are fair, just, and
equitable after consideration of the financial status of the parties.
SECTION 3.
ASSETS
Husband Initials:___________ Wife Initials: ___________
In General . Husband and Wife are in possession of all personal property belonging to
each, and neither makes any claim to any personal property in the possession of the other
except as otherwise provided herein. There is no joint property to divide. Except as
otherwise provided herein, all property titled in the name of Husband shall be and remain
his and all property titled in the name of Wife shall be and remain hers.
Retirement Accounts . The parties represent that all retirement and pension types of
accounts have been disclosed and agree that there will not be a division of retirement
pension accounts and each party shall keep their respective retirement and pension type
accounts.
Life Insurance . Except as otherwise provided herein, the parties agree that they will
remove each other’s names from their respective life insurance policies. Further, that
from and after the date of this Agreement, husband and wife disclaim, waive and
renounce the right to receive any life insurance benefits or proceeds, if any, to which they
would have been entitled as beneficiary on a life policy maintained by the other even if
they have not been removed as the designated beneficiary on the date of death of the
insured.
Household Furnishing and Effects. (Select as appropriate)
The household furnishings and effects of the parties have been mutually divided by
the parties and neither makes claim to any such property in the possession of the other
except as provided below.
Wife agrees that the Husband shall retain all of the household furnishings and effects
presently located on the premises at ________________________________________,
excepting those items already removed by the Wife, or to be removed, with the
Husband’s permission, or as provided below.
Husband agrees that the Wife shall retain all of the household furnishings and effects
presently located on the premises at _________________________________________,
excepting those items already removed by the Husband, or to be removed, with the
Wife's permission, or as provided below.
Husband shall be entitled to possession of the following household furnishing and
effects:
_______________________________________________________________________
Husband Initials:___________ Wife Initials: ___________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Wife shall be entitled to possession of the following household furnishings and effects:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Each party shall retain as his or her own all of their personal clothing, jewelry and
effects.
Marital Home .
Husband owns improved premises, which has been occupied as the marital residence
of the parties located at ___________________________________________________.
It is understood and agreed that the Husband shall remain and live in the house and be
fully responsible for its mortgage payments and utility charges and other expenses, if
any, in connection with the same. Wife shall retain no interest in said home, legal or
equitable.
Wife owns improved premises, which has been occupied as the marital residence of
the parties located at ______________________________________________________.
It is understood and agreed that the Wife shall remain and live in the house and be fully
responsible for its mortgage payments and utility charges and other expenses, if any, in
connection with the same. Husband shall retain no interest in said home, legal or
equitable.
Husband and Wife rent premises, which has been occupied as the marital residence
of the parties located at _____________________________________. It is understood
and agreed that the Wife shall remain and live in the rental premises and be fully
responsible for all rental payments and utility charges and other expenses in connection
with the same. Husband shall retain no interest in said premises, legal or equitable.
Husband and Wife rent premises, which has been occupied as the marital residence
Husband Initials:___________ Wife Initials: ___________
of the parties located at _____________________________________. It is understood
and agreed that the Husband shall remain and live in the rental premises and be fully
responsible for all rental payments and utility charges and other expenses in connection
with the same. Wife shall retain no interest in said premises, legal or equitable.
Other: _______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
SECTION 4.
DEBTS, LIABILITIES AND EXPENSES
Each party agrees to pay their respective debts and agree that there are no joint debts that
remain unpaid at the time of the execution of this Agreement. Husband shall pay his debts and
Wife shall pay her debts.
Each party agrees to be fully responsible for their own individual medical expenses and
will maintain their own medical plans, which they may carry either individually or through their
place of employment.
SECTION 5.
FUTURE EARNINGS AND ACQUISITIONS
All income, earnings, or other property received or acquired by either party to this
Agreement on or after the date of execution of this Agreement shall be the sole and
separate property of the receiving or acquiring party. Each party, as of the effective date
of this Agreement, does hereby and forever waive, release, and relinquish all right, title,
and interest in all such income, earnings and other property except as necessary to collect
any sums due hereunder in the event of default.
SECTION 6.
SPOUSAL SUPPORT (ALIMONY)
[ one only]
_________ 1. In consideration of the provisions contained herein for the respective
benefits of the parties and other good and valuable considerations, the parties hereto
mutually waive any and all claim or right to temporary or permanent alimony,
maintenance or support, whether past, present or future. Thus, each of the parties
Husband Initials:___________ Wife Initials: ___________
forever give up any right to spousal support (alimony) that they may have from the
other.
__________ 2. ( ) Husband ( ) Wife agrees to pay spousal support (alimony) in the
amount of $ ___________ every ( ) week ( ) other week ( ) month, beginning
__________________ {date} and continuing until ______________________________
{date or event}.
Explain type of alimony (temporary, permanent, rehabilitative, and/or lump sum) and
any other specifics:
[ if applies]
( ) Life insurance in the amount of $ to secure the above support, will be
provided by the obligor.
SECTION 7.
CHILD CUSTODY, PARENTAL RESPONSIBILITY, AND VISITATION
A. The following child(ren) have been born to the marriage of the parties:
Name Birth date
_________________________ _____________
_________________________ _____________
_________________________ _____________
_________________________ _____________
B. Parental Responsibility Child Custody
Both Husband and Wife are proper persons to have the permanent legal and
physical custody, parental responsibility, care and control of the minor children of
the parties. Husband and Wife shall share the decision-making rights, the
responsibilities and the authority relating to the health, education and welfare of
the children, and shall, therefore, make joint decisions concerning the children’s
health, education and welfare. Both Husband and Wife shall exchange
information concerning the health, education and welfare of the minor children,
Husband Initials:___________ Wife Initials: ___________
and shall confer with one another in the exercise of decision-making rights,
responsibilities and authority. Husband and Wife shall have equal access to all
medical, dental and school records concerning the minor children.
However, the parties agree that the best interest of the child(ren) at this time is
that primary parental responsibility and physical custody of the minor child(ren)
will be and agree as follows:
( ) Husband shall have primary parental responsibility and custody of the
minor child(ren) of the parties subject to the visitation rights of Wife.
( ) Wife shall have primary parental responsibility and custody of the
minor child(ren) of the parties subject to the visitation rights of Husband.
( ) Husband and Wife shall have joint primary parental responsibility and
custody of the minor child(ren) of the parties, both legal and physical.
C. Secondary Parental Responsibility, Visitation, or Time Sharing -
General Provisions .
Visitation shall be conducted pursuant the following general provisions:
i) Visitation should be pleasant for the children and for the parent.
Visitation should help the children maintain a good relationship
with the non-custodial parent.
ii) Visitation means the visiting parent will have the children visit in
his or her home overnight. It may include trips and outings
elsewhere.
iii) Visitation schedules shall be followed and the visiting parent shall
inform the other parent when he or she cannot comply with the
schedule.
iv) Adjustment of the visitation schedule from time to time may be
necessary according to the children's ages, health and interests.
v) Visitation should provide meaningful personal contact for both the
visiting parent and the children.
vi) Visitation should not be used to check on the other parent and the
children should not be questioned for information about the other
parent.
Husband Initials:___________ Wife Initials: ___________
vii) Both parents should strive to agree on matters pertaining to the
children, including discipline, so that one parent is not
undermining the other parent's efforts.
viii) It is in the child's best interest for each parent to have a frequent,
meaningful and continuing relationship with their children. For
children to make an adequate adjustment to the dissolution of their
parents marriage, the children must be allowed to continue their
relationship with both parents, experience minimal changes in their
lifestyle if at all possible, and not experience post-divorce conflict
between their parents.
D. Secondary Parental Responsibility, Visitation, or Time Sharing Schedule.
The non-custodial parent is entitled to reasonable visitation with the minor
child(ren). Husband and Wife adopt the following visitation schedule for the non-
custodial parent:
Birth to 1 Year of Age
i) Non-custodial parent shall have four (4) visits with the child per
week, with such contact lasting four (4) hours in length.
ii) If the child is taken from the home of the custodial parent, the
child shall be returned at least one (1) hour before evening
bedtime.
iii) Holiday Access
Holiday access takes precedence over the regularly scheduled
visitation plan.
The non-custodial parent shall be entitled to the following:
On each child's birthday from 5:00 p.m. until 8.00 p.m.;
Memorial Day Monday from 2:00 p.m. until 6:00 p.m.;
Labor Day Monday from 2:00 p.m. until 6:00 p.m.;
Thanksgiving Day from 2:00 p.m. until 6:00 p.m.;
Christmas Day from 2:00 p.m. until 6:00 p.m.;
Independence Day from 2:00 p.m. until 6:00 p.m.;
Mother's Day with Mother from 2:00 p.m. until 4:00 p.m. and
Father's Day with Father from 2:00 p.m. until 4:00 p.m.
1 Year of Age to 5 Years of Age
Husband Initials:___________ Wife Initials: ___________
i) The non-custodial parent shall have access on alternate weekends
from Friday at 6:00 p.m. until Sunday at 6:00 p.m.
ii) Additionally, the non-custodial parent shall be permitted one (1)
week night each and every week with the child from 5:30 p.m.
until 7:30 p.m.
iii) Holiday Access
Holiday access takes precedence over the regularly scheduled
access/visitation plan.
The non-custodial parent shall be entitled to the following:
In years ending in an odd number:
The night before each child's birthday from 5:00 p.m. until 8:00
p.m.;
Memorial Day Monday from 9:00 a.m. until 6:00 p.m.;
Independence Day from 9:00 a.m. until 6:00 p.m.;
Thanksgiving Day from 9:00 a.m. until 6:00 p.m.;
Christmas Eve from 6:00 p.m. until Christmas Day at 10:00 a.m.;
In years ending in an even number:
Each child's birthday from 5:30 p.m. until 7:30 p.m.;
Easter from 8:00 a.m. until 6:00 p.m.;
Labor Day Monday from 9:00 a.m. until 6:00 p.m.;
Halloween evening from 5:30 p.m. until 8:00 p.m.;
Christmas Day from 10:00 a.m. until 7:00 p.m.
iv) Summer Visitation
The non-custodial parent shall have one (1) week of vacation with
the children each June, July and August of each year. The non-
custodial parent shall notify the custodial parent in writing no later
than May 1st of each year as to the specific weeks of such summer
visitation.
5 Years of Age and Beyond
i) Non-custodial parent shall have access with the child on
alternate weekends from Friday at 6:00 p.m. until Sunday
at 6:00 p.m. and on the Wednesday preceding the weekend
access from 5:30 p.m. to 7:30 p.m.
ii) In addition, the non-custodial parent shall have access with
the child during the week immediately following the
Husband Initials:___________ Wife Initials: ___________
weekend visitation on Tuesday and Thursday evening from
5:30 p.m. until 7:30 p.m.
iii) Holiday Access:
Holiday access takes precedence over the regularly
scheduled access/visitation plan.
The non-custodial parent shall be entitled to the following:
In years ending in an odd number:
The night before each child's birthday from 5:00 p.m. to
8:00 p.m.;
Spring Break from Friday at 6:00 p.m. to the Sunday prior
to the start of school at 6:00 p.m.;
Memorial Day weekend from 6:00 p.m. on Friday until
6:00 p.m. on Monday;
Independence Day from 6:00 p.m. on July 3rd until 6:00
p.m. on July 5th;
Thanksgiving holiday from 6:00 p.m. on Wednesday until
6:00 p.m. on Sunday;
From 6:00 p.m. on December 26th until
6:00 p.m. on January 1st.
In years ending in an even number:
Each child's birthday from 5:30 p.m. until 7:30 p.m.;
Easter weekend from 6:00 p.m. on Good Friday until 6:00
p.m. on Easter Sunday;
Labor Day weekend from 6:00 p.m. on Friday until 6:00
p.m. on Monday;
Halloween evening from 5: 30 p.m. until 9:00 p.m.
Christmas holiday from 6:00 p.m. on December 20th until
6:00 p.m. on December 26th.
iv) Mother's Day/Father's Day
The mother shall have access every Mother's Day weekend
from Friday at 6:00 p.m. until Sunday at 6:00 p.m.; the
father shall have access every Father's Day weekend from
Friday at 6:00 p.m. until Sunday at 6:00 p.m.
Husband Initials:___________ Wife Initials: ___________
v) Summer Visitation:
The non-custodial parent shall have five (5) weeks of
summer visitation with the child to be taken in no more
than two (2) week intervals and with such weekly or two
(2) week visits to be nonconsecutive. The non-custodial
parent shall notify the custodial parent in writing no later
than May 1st of each year as to the specific weeks of such
summer visitation.
E. Secondary Parental Responsibility, Visitation, or Time Sharing Additional
Provisions.
In exercising visitation rights the following additional provisions apply:
1. Conflicts Between Regular Weekend, Holiday, and Extended Summer
Visitation. Where there is a conflict between a holiday weekend and the
regular weekend visitation, the holiday takes precedence. Thus, if the
non-custodial parent misses a regular weekend because it is the custodial
parent's holiday, the regular alternating visitation schedule will resume
following the holiday. If the non-custodial parent received two
consecutive weekends because of a holiday, the child will spend the
following weekend with the custodial parent. When there is a conflict
between holiday visitation and extended summer visitation, the holiday
visitation takes precedence. When there is a conflict between regular
weekend visitation and extended summer visitation, extended summer
visitation takes precedence.
2. Appropriate Conduct By Parents . Parents shall, at all times, avoid
speaking negatively about each other and should firmly discourage such
conduct by relatives or friends. Each parent should encourage the
children to support the other parent. The basic rules of conduct and
discipline established by the custodial parent should be the baseline
standard for both parents, and consistently enforced by both, so that the
children do not receive mixed signals.
3. Parental Communication. Parents shall at all times keep each other
advised of their home and work addresses and telephone numbers. So far
as possible, all communication concerning the children shall be conducted
between the parents in person, or telephonically at their residences (and
not at their places of employment).
4. Grade Reports and Medical Information. The custodial parent shall
provide the non-custodial parent with grade reports and notices from
school as they are received and shall, consistent with ___________ law,
permit the non-custodial parent to communicate concerning the children
directly with the school and with the children's doctors and other
professionals, outside the presence of the custodial parent. Each parent
Husband Initials:___________ Wife Initials: ___________
shall immediately notify the other of any medical emergencies or serious
illnesses of the children. The custodial parent shall notify the non-
custodial parent of all school or other events (like Church or Scouts)
involving parental participation. If the children are taking medications,
the custodial parent shall provide a sufficient amount and appropriate
instructions.
5. Visitation Clothing. The custodial parent shall send an appropriate
supply of the children's clothing with them, which shall be returned clean
(when reasonably possible), with the children, by the non-custodial parent.
The non-custodial parent shall advise, as far in advance as possible, of any
special activities so that the appropriate clothing may be sent.
6. Visitation or Support Disputes. Neither visitation nor child support is to
be withheld because of either parent's failure to comply with a court order.
The children have a right to both support and visitation, neither of which
is dependent upon the other. In other words, failure to pay support does
not mean no visitation and no visitation does not mean no support. If
there is a violation of either a visitation or a support order, the exclusive
remedy is to apply to the court for appropriate sanctions.
7. Adjustments to This Visitation Schedule. Although this is a rather
specific schedule, the parties are expected to fairly modify visitation when
family necessities, illnesses or commitments reasonably so require. The
requesting party shall give as much notice as circumstances permit.
8. Pickup and Drop-off. Unless other arrangements are made, the
non-custodial parent shall pick up the children at the times specified and
return them at the times specified. The custodial parent shall have the
children ready for visitation at the time they are to be picked up and shall
be present at the home to receive the children at the time they are
returned. Unjustified violations of this provision may result in the
offender being subject to contempt of court. (Commentary: While it is
most desirable for the parents to pick up and return the children, this
provision does not prohibit grandparents, current spouses or other
appropriate adults known to the children.)
9. Extracurricular Activities. Children are often involved in sports,
lessons, and other extracurricular activities, which are generally to their
benefit and enjoyment. Each parent shall recognize that a reasonable
amount of extracurricular activities are generally assumed to be in the
children's best interests. Each parent should attempt to be flexible in order
to accommodate the children's extracurricular activity schedules as must
as reasonably possible, although extracurricular activities should not
supersede summer visitation with non-custodial parents, nor should they
be used as a method by which to deny access to the non-custodial parent.
In recognition of the scheduling difficulties that can be caused by
children's extracurricular activities, custodial parents should act in good
Husband Initials:___________ Wife Initials: ___________
faith in attempting to schedule such extracurricular activities as not to
unreasonably infringe upon the non-custodial parent's access to the
children. Likewise, the non-custodial parent should act in good faith in
attempting to assist in transportation needs and in accommodating the
children's extracurricular schedules as much as reasonably possible. Good
faith communication by the parents is essential with regard to the difficult
issue of the scheduling of children's extracurricular activities.
10. Notice of Canceled Visitation. Whenever possible, the non-custodial
parent shall give a minimum of three (3) days notice of intent not to
exercise all or part of the scheduled visitation. When such notice is not
reasonably possible, the maximum notice permitted by the circumstances,
and the reason therefore, shall be given. The custodial parent shall give
the same type of notice when good cause exists making the cancellation or
modification of scheduled visitation necessary.
11. Missed Visitation. In the event the non-custodial parent misses visitation
as the result of illness of the child or parent, an emergency, or other such
reasonable excuse, the parties shall make a good faith effort to make up a
portion of that visitation within a reasonable period of time, understanding
the importance of the non-custodial parent's continuing and frequent
contact with the children. (Commentary: It is important to remember that
illness should not necessarily deprive the non-custodial parent of visitation
with the children. Clearly, a non-custodial parent can take care of a sick
child as well as the custodial parent in many circumstances.)
12. Custodial Parent's Vacation. Unless otherwise specified, the custodial
parent shall be entitled to a period of vacation with the children no less
than that accorded the non-custodial parent, whose visitation shall abate
during the first fourteen days thereof, and thereafter only so long as
distance makes visitation impracticable.
13. Caretaker Provision. As a general rule, each parent shall have the right
of first refusal for childcare or baby sitting needs of the other parent for
durations of four hours or more. Whenever either parent has a need for
child care or baby sitting for a duration of four hours or more, that parent
should always make a good faith attempt first to inquire of the other
parent, with as much advance notice as reasonably possible, whether the
other parent desires to provide child care or baby sitting. The other parent
is under no obligation to provide the childcare or baby-sitting. If the other
parent elects to provide such childcare or baby sitting, it shall be done at
no cost. This provision is intended to provide each parent additional
access to the children whenever reasonably possible.
14. Telephone and Mail Privileges. Each parent shall allow liberal and
reasonable telephone and mail privileges with the children.
Husband Initials:___________ Wife Initials: ___________
15. Medical Reports and Bills. The Custodial parent shall provide copies of
all medical information, and documentation, including bills, within seven
(7) days of their receipt and shall immediately notify the other parent in
the event of a medical emergency. Every effort shall be made for the
custodial parent to provide the non-custodial parent with the necessary
information of a medical expense in order to get the bill satisfied. The
parent with the medical insurance shall provide the other parent with a
copy of the explanation of benefits within seven (7) days from the date of
receipt of same so that the uninsured portion of the bill can be quickly
calculated and paid within a reasonable period of time.
16. Abatement of Support During Extended Visitation. If the non-
custodial parent's support obligation is current, support shall abate by 50
percent during any visitation of seven (7) consecutive days or more. If
support is not current, the 50 percent that would have been abated shall be
paid and shall apply to the existing arrearage. (Commentary: If the
custodial parent actually receives the full amount of child support during
this period and if support is current, it is the custodial parent's obligation
to refund the money immediately to the non-custodial parent. This
alleviates many of the problems that arise when wage-withholding orders
have been issued.)
17. Modification. If the parties mutually agree permanently to change the
provisions of their decree of divorce, they must petition the Court to
approve and order that change. In the event that the parties do not obtain a
court order, the Court will not be bound by any alleged agreement of the
parties.
F. Other Provisions.
{explain any other agreed-upon arrangements}
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Neither parent shall take the child(ren) from the custody of the other parent or
any child care provider or other person entrusted by the other parent with the care
of the child(ren) without the agreement of the other party during the other party’s
time of parental responsibility or visitation.
Husband Initials:___________ Wife Initials: ___________
SECTION 8.
CHILD SUPPORT, HEALTH INSURANCE, DENTAL INSURANCE
A. Amount and Person to Pay. ( ) Husband ( ) Wife will pay child support to (
) Wife ( ) Husband for the benefit of the minor children of the parties in the
amount of $____________ , per child, every ( ) week ( ) other week ( )
month, beginning ______________________ {date} and continuing until
modified by court order, or the minor child(ren) becomes an adult, emancipated,
marries, dies, otherwise becomes self-supporting. (Note: Child support is stated
in terms of amount per child.)
B. Child Support Arrearage. There currently is a child support arrearage of
$ _________________ for retroactive child support and/or $ for
previously ordered unpaid child support. The total of $ in child
support arrearage shall be repaid at the rate of $ every ( ) week ( ) other
week ( ) month, beginning _______________________, until paid in full
including statutory interest.
C. Health Insurance. ( ) Husband ( ) Wife will ( ) maintain health insurance
coverage for the parties’ minor child(ren). The party providing coverage will
provide insurance cards to the other party showing coverage. OR ( ) Health
insurance is not reasonably available at this time. Any uninsured/ unreimbursed
medical costs for the minor child(ren) shall be assessed as follows:
( ) a. Shared equally by both parents.
( ) b. Prorated according to the child support guideline percentages.
( ) c. Other {explain} :_____________________________________
__________________________________________________________
As to these uninsured/unreimbursed medical expenses, the party who incurs the
expense shall submit a request for reimbursement to the other party within 30
days, and the other party, within 30 days of receipt, shall submit the applicable
reimbursement for that expense, according to the schedule of reimbursement set
out in this paragraph.
Husband Initials:___________ Wife Initials: ___________
D. Dental Insurance. ( ) Husband ( ) Wife will maintain ( ) dental insurance
coverage for the parties’ minor child(ren). The party providing coverage will
provide insurance cards to the other party showing coverage. OR ( ) dental
insurance is not reasonably available at this time. Any uninsured/ unreimbursed
dental costs for the minor child(ren) shall be assessed as follows:
( ) a. Shared equally by both parents.
( ) b. Prorated according to the child support guideline percentages.
( ) c. Other {explain} :____________________________________
______________________________________________________
As to these uninsured/unreimbursed dental expenses, the party who incurs the
expense shall submit a request for reimbursement to the other party within 30
days, and the other party, within 30 days of receipt, shall submit the applicable
reimbursement for that expense, according to the schedule of reimbursement set
out in this paragraph.
E. Life Insurance. ( ) Husband ( ) Wife shall be required to maintain life
insurance coverage for the benefit of the parties’ minor child(ren) in the amount
of $ until the youngest child becomes an adult, becomes emancipated,
marries, dies, or otherwise becomes self-supporting.
F. IRS Income Tax Deduction(s). The parent granted primary residential
responsibility or sole parental responsibility of the parties’ minor child(ren) shall
have the benefit of any tax deductions for the child(ren) or as follows {explain} :
__________________________________________________________________
__________________________________________________________________
The other parent will convey any applicable IRS form regarding the income tax
deduction.
G. Other provisions relating to child support (e.g., uninsured medical/dental
expenses, insurance coverage, life insurance to secure child support, orthodontic
payments, college fund, etc.):
__________________________________________________________________
Husband Initials:___________ Wife Initials: ___________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
F. Insurance coverage, life insurance to secure child support, orthodontic payments,
college fund, etc.): __________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
SECTION 9.
MUTUAL INDEMNITY
The parties agree in regard to the payment of debts and other liabilities as stated in this
Agreement that each shall indemnify and hold harmless the other for the payment of
same.
SECTION 10.
INCOME TAXES
With respect to any earlier year in which the parties filed joint Federal and State Income
Tax Returns, each party agrees to indemnify the other for any income tax liability,
penalty or deficiency associated with his or her income and shall hold the other party
harmless therefor.
The parties shall file separately for the year _______ and each year thereafter.
The parties acknowledge that they have been advised that there may be certain tax
consequences pertaining to this Agreement and have been directed and advised to obtain
independent tax advice from qualified tax accountants or tax counsel prior to signing
this Agreement, and that each party has had an opportunity to do so.
SECTION 11.
ADDITIONAL OR FURTHER DOCUMENTS; COOPERATION
Husband Initials:___________ Wife Initials: ___________
Each party agrees that he or she will sign and execute any further or additional
documents as may be necessary to put into effect the intended purposes hereof. Each
party shall execute, acknowledge and deliver to the other party any and all instruments
and assurances that the other party may reasonably require or find convenient, expedient,
or businesslike for the purpose of giving full force and effect to the provisions of this
Agreement, specifically including any deeds, affidavits, tax forms or other instruments
required of one party to the other in order to pass good or merchantable title to any
property owned by either party during the marital relationship.
SECTION 12.
DIVORCE
It is agreed and understood that this Agreement finally settles all rights of the parties and
the property jointly or individually owned by the parties, and that this Agreement, and
the enforceability thereof, is not contingent upon either party or both parties being
granted a divorce on any grounds. However, if either or both parties are granted a
divorce on any grounds, the parties agree that this Agreement shall be made a part
thereof and that such decree or judgment shall not conflict with the terms hereof except
to the extent disapproved by the Court. In the event that the law governing this
Agreement prohibits this Agreement from being effective until a divorce action has been
filed, or a Judgment of Divorce entered, then the parties agree that such event shall be the
effective date of this Agreement. In the event a divorce action or judgment is required
prior to this Agreement becoming effective, or in the event that a divorce action is
desired by one or more of the parties, both parties agree and sign and execute all pleading
and papers required to obtain a divorce and jointly request and consent to the immediate
submission of this Agreement to the applicable Court and to an entry of a judgment by
incorporation of this Agreement into the final decree or judgment of divorce.
SECTION 13.
MODIFICATION
This Agreement shall stop and preclude either party from making other or further
demands and claims upon the other, not included herein, except that such legal action
Husband Initials:___________ Wife Initials: ___________
may be taken by either party as is necessary to enforce or modify the terms and
provisions hereof, except that the Property Settlement provision shall not be subject to
modification.
SECTION 14.
ABSENCE OF DURESS OR UNDUE INFLUENCE
The parties agree and state that each has freely and voluntarily entered into this
Agreement. This Agreement was executed free of any duress, coercion, collusion, or
undue influence. In some instances, the Agreement represents a compromise of
disputed issues; however, both parties believe that its terms and conditions are fair
and reasonable.
SECTION 15.
RELEASE, WAIVER, BINDING EFFECT, AND ESTATES
Except as otherwise provided for in this Agreement, each party shall be divested of and
each party waives, renounces and gives up all right, title and interest in and to the
property awarded to the other. All property and money received and retained by the
parties shall be the separate property of the respective party, except as is specifically
stated herein.
Except for those rights and obligations contained in this Agreement, or arising therefrom
by operation of law, both parties do hereby release and forever discharge the other party
from all actions, causes of actions, claims and demands whatsoever, known and
unknown, suspected and unsuspected, apparent now or hereafter. It is the specific
agreement and purpose of this paragraph to release and discharge any and all claims and
causes of actions of any kind or nature whatsoever whether specifically mentioned or
not, which may exist or might be claimed to exist at or prior to the date of this
Agreement; and, both parties specifically waive any claim or right to assert that any
cause of action or alleged cause of action or claim or demand has been, through
oversight or error or intentionally or unintentionally, omitted from this release and
agreement.
The parties shall refrain from, release and relinquish any and all claim that he or she
may have had, may now have, or may hereafter acquire to share in any capacity or to
any extent whatsoever, in the estate of the other, whether by way of statutory allowance,
Husband Initials:___________ Wife Initials: ___________
heirship, homestead rights, or election to take against or under the other party’s Last
Will and Testament. It is the intent of the parties that neither shall be a beneficiary or
recipient of property of the other by Will or intestate succession from and after the date
of this agreement and expressly waive and reliquinsh any such right regardless of
whether the Will of the other has been changed to delete the gift to her or him and
regardless of whether one party shall die prior to the entry of a final judgment of
divorce.
SECTION 16.
ENFORCEMENT
This Agreement may be enforced by actions and proceedings for Contempt of Court, or
attachment and garnishment, for specific performance, or any other remedy legally
available to either Husband or Wife, for the enforcement of the provisions and covenants
of this Agreement.
SECTION 17.
BANKRUPTCY
To the extent of any obligation contained herein is discharged in bankruptcy and the non-
bankrupt party is held liable for said debt, the non-bankrupt party shall have the right to
petition a court of competent jurisdiction for spousal support in an amount sufficient to
cover any amounts so discharged.
SECTION 18.
ENTIRE AGREEMENT
This Agreement constitutes the entire Agreement between the parties and each party
acknowledges that there are no further agreements not expressly included herein and that
this Agreement may be modified, altered, or amended only in writing, duly signed and
notarized by each in the form of this original.
SECTION 19.
FULLY READ AND UNDERSTAND; INFORMED CONSENT
Each party represents and acknowledges that he or she has fully read this Agreement,
consulted with each other, carefully considered same, and have signed and executed same
Husband Initials:___________ Wife Initials: ___________
after such consultation, that the signing of this Agreement is free and voluntary without
force or collusion by either party or any third party, and that each party signed same with
the full knowledge of said party's rights, obligations, and responsibilities. Each party
agrees that they have had a reasonable opportunity to consult with an attorney of their
choice in the negotiation and preparation of this document, and regarding any divorce
proceeding.
SECTION 20.
SEVERABILITY
If any portion of the Agreement shall be held to be void, voidable or unenforceable for
any reason, then all the remaining parts or portions shall be construed, implemented and
administered as if such void, voidable or unenforceable portion did not appear herein.
SECTION 21.
CONTROLLING LAW
This Agreement shall be governed, enforced and interpreted according to the laws of the
State of Kentucky.
SECTION 22.
HEIRS AND ASSIGNS
This Agreement shall be binding upon their legal representatives, successor, heirs and
assigns.
EXECUTED AND AGREED ON THE DATES SET FORTH BELOW. I certify that I
have been open and honest in entering into this Settlement Agreement. I am satisfied
with this Agreement and intend to be bound by it.
Dated:
Signature of Wife
Printed Name: _____________________________
Address: __________________________________
City, State, Zip:
Telephone Number:
Fax Number:
Dated:
Signature of Husband
Husband Initials:___________ Wife Initials: ___________
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
State of Kentucky
County of _____________________
The foregoing instrument was acknowledged before me this _________________ (date)
by _____________________________________ (name of person acknowledged).
______________________________
Notary Public
Title (and Rank): _______________
Print Name: ___________________
(Seal, if any)
My commission expires: ________________
State of Kentucky
County of _____________________
The foregoing instrument was acknowledged before me this _________________ (date)
by _____________________________________ (name of person acknowledged).
______________________________
Notary Public
Title (and Rank): _______________
Print Name: ___________________
(Seal, if any)
My commission expires: _______________
Husband Initials:___________ Wife Initials: ___________
