AR-DO-10
INSTRUCTIONS
When should this form be used?
This form should be used when the parties desire to enter into a Separation Agreement in
contemplation of a divorce, which has been filed or will be filed prior to effective date of this
Agreement. This form is for married persons with children. No joint property or debts.
This form is the State of Arkansas.
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 when approved by the
appropriate Court. The parties will file a divorce proceeding prior to signing this Agreement, or
have pending a divorce action at the time of execution.
Husband Initials:___________ Wife Initials: ___________ Page 0
IN THE CHANCERY COURT OF ___________________ COUNTY, ARKANSAS
In Re the Marriage of: )
)
____________________________ )
)
) NO. _______________________
v. )
)
____________________________ )
)
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 ARKANSAS
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, _________________,
Husband Initials:___________ Wife Initials: ___________ Page 1
and since that date have been living separate and apart; and
WHEREAS, differences have arisen between the parties that have resulted in the parties
electing to live separate and apart. The parties make this Agreement to settle once and for all
what 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 and child custody, support and visitation. 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
WHEREAS, the parties intend that this Agreement shall be binding and effective subject
to approval by the Court in that certain action pending in the Chancery Court of
______________ County, Arkansas, Cause Number _______________, which is a divorce
action involving Husband and Wife.
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
Husband Initials:___________ Wife Initials: ___________ Page 2
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
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 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 in this agreement, 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
Husband Initials:___________ Wife Initials: ___________ Page 3
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:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Wife shall be entitled to possession of the following household furnishings and effects:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Husband Initials:___________ Wife Initials: ___________ Page 4
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
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
Husband Initials:___________ Wife Initials: ___________ Page 5
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 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:
Husband Initials:___________ Wife Initials: ___________ Page 6
[ 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, 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
Husband Initials:___________ Wife Initials: ___________ Page 7
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 has 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.
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.
Husband Initials:___________ Wife Initials: ___________ Page 8
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. unti1 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.;
Husband Initials:___________ Wife Initials: ___________ Page 9
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
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. unti16:00 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. unti1 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.;
Husband Initials:___________ Wife Initials: ___________ Page 10
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 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.;
Husband Initials:___________ Wife Initials: ___________ Page 11
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.
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:
Husband Initials:___________ Wife Initials: ___________ Page 12
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 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.
Husband Initials:___________ Wife Initials: ___________ Page 13
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 aright
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
Husband Initials:___________ Wife Initials: ___________ Page 14
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 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.
Husband Initials:___________ Wife Initials: ___________ Page 15
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.
15. Medical Reports and Bills. The Custodial parent shall provide copies of all
medical information, and documentation, including bins, 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
Husband Initials:___________ Wife Initials: ___________ Page 16
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.
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
Husband Initials:___________ Wife Initials: ___________ Page 17
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.
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} :
Husband Initials:___________ Wife Initials: ___________ Page 18
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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.):
_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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.
Husband Initials:___________ Wife Initials: ___________ Page 19
SECTION 11.
ADDITIONAL OR FURTHER DOCUMENTS; COOPERATION
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 shall be
incorporated into judgment of the Chancery Court of _____________ County, Arkansas, Cause
Number _______________. The parties agree that this Agreement shall be made a part of a
final decree or judgment and such decree or judgment shall not conflict with the terms hereof
except to the extent disapproved by the Court. The parties agree that each mutually submits to
the personal jurisdiction of the Chancery Court of __________________ County, Arkansas, so
that said Court has the power to decide any and all matters and questions concerning the
dissolution of the parties’ marriage, and the division of the parties’ property and debts.
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 may be
Husband Initials:___________ Wife Initials: ___________ Page 20
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, it represents a compromise of disputed issues; however, the
parties believe that the terms and conditions of the Agreement 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 claims 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, heirship,
homestead rights, or election to take against or under the other party’s Last Will and Testament.
Husband Initials:___________ Wife Initials: ___________ Page 21
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.
Husband Initials:___________ Wife Initials: ___________ Page 22
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 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 Arkansas.
SECTION 22.
EFFECTIVE DATE; HEIRS AND ASSIGNS
This agreement shall be binding upon the parties and their legal representatives,
successor, heirs and assigns, subject to approval by the Court in which divorce proceedings are
instituted or pending.
Husband Initials:___________ Wife Initials: ___________ Page 23
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
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
STATE OF ARKANSAS
COUNTY OF _________________
On this the _______ day of ________________, 20____, before me,
______________________, the undersigned officer, personally appeared
________________________________________, known to me (or satisfactorily proven) to be
the person whose name is/are subscribed to the within instrument and acknowledged that
he/she/they executed the same for the purposes therein contained.
Husband Initials:___________ Wife Initials: ___________ Page 24
In witness whereof I hereunto set my hand and official seal.
_________________________________
Notary Public
Printed Name: _____________________
My Commission Expires: _________________
STATE OF ARKANSAS
COUNTY OF _________________
On this the _______ day of ________________, 20____, before me,
______________________, the undersigned officer, personally appeared
________________________________________, known to me (or satisfactorily proven) to be
the person whose name is/are subscribed to the within instrument and acknowledged that
he/she/they executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
_________________________________
Notary Public
Printed Name: _____________________
My Commission Expires: _________________
Husband Initials:___________ Wife Initials: ___________ Page 25
