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Perio d o f r e sid ence to present Addre ss Confid entia lPers o n c h ild liv e d w it h ( n am e a nd p re se nt a ddre ss) R ela tio nsh ip totototo P erio d o f r e sid ence to present Addre ss Confid e ntia l Pers o n c h ild liv e d w it h ( n am e a nd p re se nt a d dre ss)R ela tio nsh ip tototo       FL-105/GC-120ATTO RNEY O R P AR TY W IT H O UT A TTO RNEY ( N am e a nd M ailin g A ddre ss):T E LE PH O NE N O .:F O R C O URT U SE O NLYA TTO RNEY F O R ( N am e):.S U PER IO R C O UR T O F C ALIF O RN IA , C O UNTY O FSTR EET A D DR ESS:M AIL IN G A D D RESSC IT Y A N D Z IP C O DE:BRANCH NAMECASE N AM E: D EC LA RATIO N U NDER U NIF O RM C HIL D C USTO DY JU RIS D IC TIO N A ND E N FO RC EM EN T A CT ( U CCJE A ) CASE N UM BER :1 . I a m a p arty t o t h is p ro ce edin g t o d ete rm in e c u sto dy o f a c h ild .2.My present address is not disclosed. It is confidential under Family Code section 3429. The address of childrenp re se ntly r e sid in g w it h d ecla ra nt is id entif ie d o n t h is d ecla ra tio n a s c o nfid entia l.3 . ( N um ber).m in or c h ild re n a re s u bje ct t o t h is p ro ce edin g a s f o llo w s:(in se rt t h e in fo rm atio n r e queste d b elo w . T he r e sid ence in fo rm atio n m ust b e g iv e n f o r t h e la st F IV E y e ars .)a . C hil d 's n am ePla ce o f b ir thD ate o f b ir thS exb. C hil d 's n am ePla ce o f b ir thD ale o f b ir thS exR esid ence in fo rm atio n is th e s a m e a s g iv e n a b ove fo r c h ild a . (If N O T t h e s a m e, p ro vid e th e in fo rm atio n b elo w .)C .A ddit io nal c h ild re n a re lis te d o n A tta ch m ent 3 c. ( P ro vid e r e queste d in fo rm atio n f o r a ddit io nal c h ild re n o n a n a tta ch m ent.) (C ontin ued o n r e ve rs e ) Form A ppro ve d fo r O ptio nal U se Ju dic ia l C ouncil o f C alif o rn ia FL -1 05/G C-1 20 [R ev. J a n uary 1 , 2 007] D EC LA RATIO N U NDER U NIF O RM C HIL D CU STO DY J U R IS D IC TIO N A N D E N FO RCEM EN T A CT ( U CCJE A ) Fam ily C ode, § 3 40 0 e t s e q. Pro bate C ode, § § 1 510 (f) , 1 512 electronic form 2006-7 WWW.LawCA.com Law Publishers 6. O ne o r m ore d om estic v io le nce r e str a in in g / p ro te ctiv e o rd ers a re n ow in e ffe ct. ( A tta ch a c o py o f t h e o rd ers if y o u h ave o ne.) Th e o rd ers a re f r o m t h e f o llo w in g c o urt o r c o urts ( s p ecif y c o unty a nd s ta te ): 7. Do y o u k n ow o f a ny p ers o n w ho is n ot a p arty t o t h is p ro ce edin g w ho h as p hysic a l c u sto dy o r c la im s t o h ave c u sto dy o f o r v is it a tio n r ig hts wit h a ny c h ild in t h is c a se ? ## #### ## ###### # ##### # ## ### ###### # ###### ######## ###### ### ### ### #### ## # SH O RT T IT LE :CASE N UM BER :4. Have you participated as a party or a witness or in some other capacity in another litigation or custody proceeding, in California or els e w here , c o n ce rn in g c u sto dy o f a c h ild s u bje ct t o t h is p ro ce edin g?N oYes (If yes, provide the following information.)a. N am e o f e ach c h ild :b. I w as ap artyw it n esso th er ( s p ecif y ):c . C ourt ( s p ecif y n am e, s ta te , lo ca tio n):d . C ourt o rd er o r ju dgm ent ( d ate ):5. Do you have information about a custody proceeding pending in a California court or any other court concerning a child subject to this p ro ce edin g, o th er t h an t h at s ta te d in it e m 4 ?N oYes ( If y e s, p ro vid e t h e f o llo w in g in fo rm atio n.)a . N am e o f e ach c h ild :b. N atu re o f p ro ce edin g:dis so lu tio n o r d iv o rc eg uard ia nsh ipa doptio noth er ( s p ecif y ):c . C ourt ( s p ecif y n am e, s ta te , lo ca tio n):d . S ta tu s o f p ro ce edin g:N oYes (If yes, provide the following information.)a. N am e a nd a ddre ss o f p ers o nb. N am e a nd a ddre ss o f p ers o nc. N am e a nd a ddre ss o f p ers o nH as p hysic a l c u sto dyH as p hysic a l c u sto dyH as p hysic a l c u sto dyC la im s c u sto dy r ig htsC la im s c u sto dy r ig htsC la im s c u sto dy r ig htsC la im s v is it a tio n r ig htsC la im s v is it a tio n r ig htsC la im s v is it a tio n r ig htsN am e o f e ach c h ildN am e o f e ach c h ildN am e o f e ach c h ildI d ecla re u nder p e nalt y o f p erju ry u nder t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :. ...............(T Y PE O R P R IN T N AM E)(S IG NATU RE O F D EC LA R AN T)7 .N um ber o f p ages a tta ch ed a fte r t h is p age:N O TIC E T O D EC LA RANT: Y ou h ave a c o ntin uin g d uty t o i n fo rm t h is c o urt i f y o u o bta in a n y i n fo rm atio n a b out a c u sto dy pro ceed in g i n a C alif o rn ia c o urt o r a n y o th er c o urt c o ncern in g a c h ild s u bje ct t o t h is p ro ceed in g.FL--1 05/G C-1 20 [R ev. J a nu ary 1 , 2 007] DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) Page tw o