Page 2 of 3 Approved by the Coalition for Court Access
CCA-DC-0519-1033
for the minor child(ren).
-OR-
☐ Health insurance for the child(ren) is not available to either parent at a reasonable
cost, therefore neither party is ordered to provide health insurance at this time. In the event that health
insurance for the child(ren) becomes available at a reasonably cost to one or both of the parties, the party to
whom such coverage is available shall obtain coverage for the children within a reasonable time after such
coverage becomes available.
6.
☐_____________________________ shall be entitled to claim the minor child(ren) for
federal, state, and local income tax purposes on an annual basis. The parties shall cooperate to sign all
necessary documents that will allow the party claiming the exemption to do so.
The non-custodial parent’s right to this exemption is conditioned on them being 95% compliant in
their support by January 31 of their tax year pursuant to IC § 31-16-6-1.5(d). The custodial parent shall take
all actions necessary to release their claim to the exemption in the manner required under Section 152(e) of
the Internal Revenue Code.
-OR-
☐Petitioner and Respondent shall each be entitled to claim the minor child(ren) for federal,
state and local income tax purposes in alternating years. Petitioner shall be entitled to claim the minor
child(ren) in the year __________, and every ______ year thereafter. Respondent shall be entitled to claim
the minor child(ren) in the year ________ and every ________ year thereafter. The parties shall cooperate
to sign all necessary documents that will allow the party claiming the exemption to do so.
The non-custodial parent’s right to this exemption is conditioned on them being 95% compliant in
their support by January 31 of their tax year pursuant to I § 31-16-6-1.5(d). The custodial parent shall take
all actions necessary to release their claim to the exemption in the manner required under Section 152(e) of
the Internal Revenue Code.
7. ________________________________ will be responsible for the first $_______________
per year of uninsured health and medical, dental, optical, hospital and prescription expenses for the minor
child(ren). Thereafter, Petitioner shall be responsible for ____% of annual uninsured health and medical,
dental, optical hospital and prescription expenses for minor child(ren), and Respondent shall be responsible