Fill and Sign the Affidavit to Proceed as a Poor Person Ncourt Form

OSCA (07-13) FA 10 1 of 2 452.400 RSMo IN THE ________ JUDICIAL CIRCUIT COURT, ______ ___________________, MISSOURI Judge or Division: Case Number: (Date File Stamp) Petitioner: SSN (Last Four Digits): Petitioner’s Address: vs. Respondent: SSN (Last Four Digits): Respondent’s Address: Motion for Family Access Order (Check each box that applies) A judgment of dissolution, legal separation or paternity was entered in ___________________ County, Missouri. The judgment of dissolution, legal s eparation or paternity was modified in ________________ County, Missouri. ____________________________________ (name) has denied or interfered with custody, visitation or third party custody under the judgment of dissolution, legal separation, paternity or modification without good cause by the following acts: (Please provide the specific facts, including dates and times, which you claim are a violation of the court’s judgment.) I request that the court find that ______________________________________(name) has denied or interfered with: (check the box that applies) Custody or visitation under the judgment. Third party custody under the judgment. I further request that _______________________________________________________________ be ordered to: (check each box that applies) Provide a period of visitation, custody or third party custody not less than the period of time denied. Participate in counseling regarding the importance of providing the child(ren) with a continuing and meaningful relationship with both parents. Participate in Alternative Dispute Resolution to assist in resolving the problems which caused the filing of this motion. Pay a fine of up to $500. Post bond or security to ensure future compliance with the court’s judgment. Pay the cost of counseling to re- establish the parent-child relationship. Pay reasonable expenses incurred as a result of the denial or interference with custody, visitation or third party custody, including attorney’s fees and court costs of the proceeding to enforce custody, visitation or third party custody. Other (specify): OSCA (07-13) FA 10 2 of 2 452.400 RSMo I swear /affirm under penalty of perjury that these facts are true according to my best knowledge and belief. ________________________________________________ ___________________________________________________ Date Your Signature ___________________________________________________ Your Street Address ___________________________________________________ City State Zip ___________________________________________________ Your Telephone Number Notice of Alternative Dispute R esolution At the initial hearing, the Court may order Alternative Dispute Resolution to assist you and the person against whom you have filed this motion in resolving the problems which caused the filing of this motion. You and the person against whom you have filed this motion may be required to attend more than one session. Any cost of the Alternative Dispute Resolution will be paid by you and the person against whom you have filed this motion in the proportions determined by the Court. Notice to ___________________________________________ (name) PURSUANT TO SECTION 452.400, RSMO, YOU ARE REQUIRED TO RESPOND TO THE CIRCUIT CLERK WITHIN TEN DAYS OF THE DATE OF SERVICE. FAILURE TO RESPOND TO THE CIRCUIT CLERK MAY RESULT IN THE FOLLOWING: 1. AN ORDER FOR A COMPENSATORY PERIOD OF CUSTODY, VISITATION OR THIRD- PARTY CUSTODY AT A TIME CONVENIENT FOR THE AGGRIEVED PARTY NOT LESS THAN THE PERIOD OF TIME DENIED; 2. PARTICIPATION BY THE VIOLATOR IN COUNSELING TO EDUCATE THE VIOLATOR ABOUT THE IMPORTANCE OF PROVIDING THE CHILD WITH A CONTINUING AND MEANINGFUL RELATIONSHIP WITH BOTH PARENTS; 3. ASSESSMENT OF A FINE OF UP TO FIVE HUNDRED DOLLARS AGAINST THE VIOLATOR; 4. REQUIRING THE VIOLATOR TO POST BOND OR SECURITY TO ENSURE FUTURE COMPLIANCE WITH THE COURT’S ORDERS; 5. ORDERING THE VIOLATOR TO PAY THE COST OF COUNSELING TO RE -ESTABLISH THE PARENT - CHILD RELATIONSHIP BETWEEN THE AGGRIEVED PARTY AND THE CHILD; AND 6. A JUDGMENT IN AN AMOUNT NOT LESS THAN THE REASONABLE EXPENSES, INCLUDING ATTORNEY’S FEES AND COURT COSTS ACTUALLY INCURRED BY THE AGGRIEVED PARTY AS RESULT OF THE DENIAL OF CUSTODY, VISITATION, OR THIRD PARTY CUSTODY. A response to this motion must be filed in writing with the Circuit Clerk of the court named above. Please keep a copy of this Motion to bring with you to any scheduled hearing or alternative dispute resolution.