JDF 1113 - Parenting Plan R: October 4, 2022 Page 7 of 9
13. Health Insurance and Costs
Check all that apply:
The Petitioner will provide
medical
dental
vision
mental health insurance for the child(ren)
in this case, except these children (list any):
The Co-Petitioner/Respondent will provide
medical
dental
vision
mental health insurance
for the child(ren) in this case, except these children (list any):
The Other Party will provide
medical
dental
vision
mental health insurance for the
child(ren) in this case, except these children (list any):
The parties will share health costs, including copays, deductibles over $250, and other costs not
covered by insurance in the following way:
The Petitioner will pay ____________ %.
The Co-Petitioner/Respondent will pay ______________ %.
The Other Party (intervenor) will pay _______________ %.
Other arrangement (describe):
Warning! If the party ordered to provide insurance does not do so, the other party may ask the party’s
employer to deduct it from his/her paycheck. See form JDF 1809
14. Optional Expenses
List any other expenses (such as private schools, university, trade school, extracurricular activities, etc.)
Check all that apply:
The parties agree to these other expenses (describe):
The parties agree to share costs for (specify): in the following way:
The Petitioner will pay _____________ %.
The Co-Petitioner/Respondent will pay _____________ %.
The Other Party will pay _____________ %.
15. Child Tax Exemption
Only one party may claim a child as a dependent on their tax return per year. If you do not make an
agreement below, follow Colorado law, which is based on your contributions to the children. §14-10-
115(12), C.R.S.
Check who will claim the child(ren) as a dependent:
Child’s Name Petitioner
Co-Petitioner/Respondent
Other
Odd Even All Odd Even All Odd Even All
Odd Even All Odd Even All Odd Even All