Fill and Sign the De Facto Parent Statement California Form

Clerk stamps below when form is filed. JV-296 De Facto Parent Statement 1 My/Our name(s): ––––– ––––– 2 The child’s name: ––––– Boy Girl 3 Child’s date of birth: ––––– Age: ––––– Relationship to child (grandparent, foster parent, etc.): Court name and street address: ––––– Superior Court of California, County of 4 The child has lived with me from: ––––– (date) ––––– to (date) ––––– ––––– (date) ––––– to (date) ––––– ––––– 5 I have had responsibility for the day-to-day care of the child from: Case Number: ––––– (date) ––––– to (date) ––––– (date) ––––– to (date) ––––– 6 Information the judge should know about my relationship with the child. (This part must be completed). a. Amount of time I spend with the child (daily, weekly, etc.): d. I have have not attended ––––– court hearings about the child. ––––– ––––– e. I have have not sent a written report to the court about the child. b. Activities I do with the child: ––––– ––––– ––––– ––––– c. Kinds of information I have about the child that others may not have (medical, educational, behavioral, etc.): ––––– ––––– ––––– 7 I declare under penalty of perjury under the laws of the State of California that the information on this form is true and correct to my knowledge. This means if I lie on this form, I am committing a crime. Date: ––––– ––––– ––––– Type or print your name Signature of person requesting de facto parent status Date: ––––– ––––– ––––– Type or print your name Signature of person requesting de facto parent status Judicial Council of California‚ JV-296, Page 1 of 1 Revised January 1, 2007, Mandatory Form De Facto Parent Statement Cal. Rules of Court‚ rule 5.534(e)