Custody and Visitation Declaration Worksheet



Custody and Visitation Declaration Worksheet

Instructions

Provide the following information on a blank separate sheet of paper following the format provided in this worksheet. Once you have completed this worksheet, you may complete your declaration using the information you provided and in the same format as the worksheet. Italicized wording can be used within your declaration. Remember to date and sign your declaration once you have completed it.

I _______________________ (state your full name) declare:

I am the ______________(Petitioner/Respondent) in the above-entitled action. I am seeking an order to:

(State here specifically what you are asking the court to do) based on the following facts:

Do orders regarding custody or visitation exist within this case? (yes or no): If yes, complete Line 1, if no, go to Line 2.

1. The Court made the following orders in this case on _______________ (date), The Court orders are as follows; (Describe what the Court ordered)

2. I request the court to make (new orders or to modify existing orders) because:

(State and number your reasons here)

1.

2.

3.

(Reasons may include but are not limited to the following: 1. Risk of immediate harm to the child(ren)

Immediate risk child(ren) will be removed from the State of California 3. Threats of harm or threats

To remove children from state or county 4. Long term lack of participation in child(ren)’s life by the non-custodial parent) Please not these are only examples and may not apply to your specific situation.

3. My first reason, ______________________ (state reason) is based on the following facts:

Provide a fully detailed description of the most recent incident/event supporting this reason based upon your personal knowledge. Continue describing incidents, starting with the most recent events. Begin a paragraph for each incident/event.

Note: When describing incidents, it is helpful to begin with specific dates/times and then describe the incident that occurred in clear and concise language. Include witnesses, any law enforcement involvement, etc., when describing incidents. State facts, not opinions, do not include statements about what others may have said or heard. Continue supporting all reasons in the same manner until you have addressed all issues.

To conclude the declaration, sign the document under penalty of perjury.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

Print Name Signature of Declarant

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