Free - Massachusetts

COMMONWEALTH OF MASSACHUSETTS THE TRIAL COURT PROBATE AND FAMILY COURT Division

Docket No:

, Plaintiff vs.

PROPOSED ORDER
, Defendant Upon the Motion for dated: and filed with this court on 20

After hearing and pending further order or judgment of this Court, IT IS ORDERED THAT
(Describe in detail the relief order you seek.) 1) shall have custody of:

the minor child/ren of the parties, 2)

shall have physical custody of said child/ren.

shall have the following visitation rights:

3)

shall pay, as child support, the sum of $ hereafter, beginning by 20

each and every to the

4) for said child/ren and for the 5)

shall obtain

insurance coverage

shall pay to the

% of the uninsured

medical, dental, hospital and optical expenses of the child/ren. 6) Other - Please specify

TEMPORARY ORDER The Court hereby adopts this proposed order, he parties shall comply with the terms and provisions thereof.

(Signature)

(Print Name)

(Street Address)

Date

Justice of the Probate Court

(City or Town)

(State)

(Zip Code) c.g.f.

Tel. No.