Fill and Sign the Declaration Custody Template Form

Superior Court of Washington County of In re the Custody of: Child(ren), Petitioner(s), and Respondent(s). No. Motion and Declaration for Temporary Nonparental Custody Order (MTAF) I. Motion 1.1 Custody Based on the reasons set forth in the declaration below, the undersigned moves the court for a temporary order which grants the undersigned custody of the following children: 1.2 Other Relief [ ] Does not apply. [ ] Based on the reasons set forth in the declaration below, the undersigned moves the court for a temporary order which: [ ] grants visitation for the mother as set forth in the attached proposed Residential Schedule, or as follows: [ ] grants visitation for the father as set forth in the attached proposed Residential Schedule, or as follows: [ ] orders child support as determined pursuant to the Washington State Support Schedule. [ ] restrains or enjoins ___________________________________ [Name] from disturbing the peace of the undersigned or of any child. M tn /D ecl T emp Nonparental Custody Ord (MTAF) - Page 1 of 4 WPF CU 03.0100 (6/200 6 ) - RCW 26.10.110; .115 [ ] restrains or enjoins____________________________________ [Name] from going onto the grounds of or entering the home, work place or school of the other party, or the day care or school of the following named child(ren): ________________________________________________________________. [ ] restrains or enjoins ______________________________________ [Name] from knowingly coming within or knowingly remaining within ___________ (distance) of the home, work place or school of the other party or the day care or school of the following children:__________________________________________________ . [ ] restrains or enjoins __________________________ [Name] from molesting, assaulting, harassing, or stalking ______________________________[Name]. [ ] restrains or enjoins______________________________ [Name] from removing any of the children from the state of Washington. [ ] ( If This Box Is Checked, Clear and Convincing Reasons for This Request Must Be Presented in the Declaration Below .) requires ______________________________ [Name] to surrender any deadly weapon in his or her immediate possession or control or subject to his or her immediate possession or control to the sheriff of the county having jurisdiction of this proceeding, to his or her lawyer or to a person designated by the court. [ ] requires ______________________________ [Name] to pay temporary attorney fees, other professional fees and costs in the amount of $ ________to: [ ] appoints a guardian ad litem on behalf of the children. [ ] Other. 1.3 Indian Child Welfare Act The moving party requests that the court enter an order finding that: Indian Child Status: [ ] The child(ren) are Indian child(ren) as defined by the Indian Child Welfare Act, 25 USC § 1903, and notice of this action must be given in accordance with 25 U.S.C. § 1912(a). [ ] None of the child(ren) are Indian child(ren) as defined by 25 U.S.C. § 1903. Jurisdiction: [ ] The child(ren) are Indian child(ren) as defined by the Indian Child Welfare Act, 25 USC § 1903, but are not domiciled or residing within the boundaries of an Indian reservation; and no Tribal Court has continuing jurisdiction over the child(ren); this court has jurisdiction under 25 USC § 1911. [ ] The child(ren) are Indian child(ren) as defined by the Indian Child Welfare Act, 25 USC Sec 1903, and are domiciled or residing within the boundaries of an Indian reservation; or a Tribal Court has continuing jurisdiction over the child(ren). Dated: Signature of Moving Party or Lawyer/WSBA No. Print or Type Name M tn /D ecl T emp Nonparental Custody Ord (MTAF) - Page 2 of 4 WPF CU 03.0100 (6/200 6 ) - RCW 26.10.110; .115 Dated: Signature of Moving Party or Lawyer/WSBA No. Print or Type Name II. Declaration It is necessary that the court issue a temporary order granting the relief requested above for the reasons set forth below: If the surrender of deadly weapons is requested, list reasons: [ ] If the nonmoving party is not present and: a) is on active duty and is a National Guard member or Reservist residing in Washington, or M tn /D ecl T emp Nonparental Custody Ord (MTAF) - Page 3 of 4 WPF CU 03.0100 (6/200 6 ) - RCW 26.10.110; .115 b) is a dependent of a National Guard member or Reservist residing in Washington on active duty, list the reasons why this temporary order should be granted despite the absence of the other party: I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at _______________________, [City] __________ [State] on _____________________ [Date]. Signature of Moving Party Print or Type Name Signed at _______________________, [City] __________ [State] on _____________________ [Date]. Signature of Moving Party Print or Type Name Do not attach financial records, personal health care records or confidential reports to this declaration. Such records should be served on the other party and filed with the court using one of these cover sheets: 1) Sealed Financial Source Documents (WPF DRPSCU 09.0220) for financial records 2) Sealed Personal Health Care Records (WPF DRPSCU 09.0260) for health records 3) Sealed Confidential Report (WPF DRPSCU 09.270) for confidential reports If filed separately using a cover sheet, the records will be sealed to protect your privacy (although they will be available to all parties in the case, their attorneys, court personnel and certain state agencies and boards.) See GR 22(C)(2). M tn /D ecl T emp Nonparental Custody Ord (MTAF) - Page 4 of 4 WPF CU 03.0100 (6/200 6 ) - RCW 26.10.110; .115