Fill and Sign the Cc Dr 5 Form

Page 1 of 2 Circuit Court for Case No. Name Street Address Apt. # City State Zip CodeArea CodeTelephoneCity or County Name Street Address Apt. # City State Zip CodeArea CodeTelephone Plaintiff Defendant COMPLAINT FOR VISITATION (CC-DR 5) I, , representing myself, state that: My name 1. I am the mother father or of the following minor child(ren): Relationship (for example, aunt, grandfather, guardian, etc.) Name of Child Date of Birth Name of Child Date of Birth Name of Child Date of Birth Name of Child Date of Birth Name of Child Date of Birth Name of Child Date of Birth 2. The child(ren) live(s) at with . Address Name and Relationship to child(ren) 3. I know of the following cases concerning the child(ren) (such as domestic violence (protective order), paternity, divorce of the child(ren)'s parents, custody, visitation, termination of parental rights, adoption or other cases): Court Case No. Kind of Case Year Filed Re\ sults or Status (if you know) Attach the most recent court order for the above-referenced court cases. 4. I have been a party, witness, or otherwise involved in the following cases about custody or visitation of the child(ren): State Court Case No. \ Date of Child Custody Determination Attach the most recent court order for the above-referenced court cases. CC-DR 5 (Rev. 10/20 15) (Check one) vs. Page 2 of 2 5. I know of the following people, not parties to this case, who have physical custody of, or claim rights of legal custody or physical custody of, or visitation with the child(ren): Name Name Name Current Address Current Address Current Address 6. It is in the best interests of the child(ren) to visit with me because: FOR THESE REASONS, I request the court grant me reasonable visitation as follows: and any other appropriate relief. I, solemnly affirm under the penalties of perjury, that the contents of this document are true to the best of my knowledge, information and belief. Date Signature Your Name CC-DR 5 (Rev. 10/20 15)