RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 1 of 14
Superior Court of Washington, County of
In re custody of :
Children :
Petitioner /s (person /s who started this case) :
Respondents (parent s and any guardian or custodian ):
No.
Residential Schedule (Non -Parent
Custody)
(PRS / TRS / RS )
[x] C lerk’ s action required: 1
Residential Schedule (N on -P arent C ustody)
1. This residential schedule is a (check one):
[ ] Proposal (request ) by a party (name /s): .
It is not a signed court order. (PRS)
[ ] Court order signed by a judge or commissioner. Thi s is a (check one) :
[ ] Temporary order . (TRS )
[ ] Final order . (RS )
[ ] This final residential schedule changes the last final residential schedule .
2. Custody – Th e Petitioner/s is/are granted custody of the following children:
Child’s name Age Chi ld’s name Age
1. 4.
2. 5.
3. 6.
3. Reasons for limiting a parent ’s visitation (under RCW 26. 10 .160 )
a. (Parent ’s name):
Abandonment, neglect, child abuse, domestic violence, assault, or sex offense.
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 2 of 14
(If this parent has any of the se problems, the court must limit his or her contact with
the child ren and right to make decision s for the child ren .)
[ ] This parent does not have any of these problems. ( Skip to 3.b.)
[ ] This parent has one or more of t hese problems as follows (check all that apply ):
[ ] Abandonment – S/he intentionally abandoned a child listed i n 2 for an
extended time.
[ ] Neglect – S/he substantially refused to perform his/her parenting duties for a
child listed i n 2.
[ ] Child Abuse – S/he (or someone liv ing in his/her home) abused or threatened
to abuse a child. The abuse was (check all that apply): [ ] physical [ ] sexual
[ ] repeated emotional abuse.
[ ] Domestic Violence – S/he (or someone living in his/her home) has a history of
domestic vi ole nce as defined in RCW 26.50.010 .
[ ] Assault – S/he (or someone living in his/her home) has assaulted or sexually
assaulted someone causing grievous physical harm or fear of such harm.
[ ] Sex Offense –
[ ] S/he has been convicted of a sex offen se as an adult.
[ ] Someone living in this parent’s home has been convicted as an adult or
adjudicated as a juvenile of a sex offense .
[ ] Other (specify):
b. (Parent ’s name):
Abandonment, neglect, child abuse, domestic violence, assault, or sex offense.
(If this parent has any of these problems, the court must limit his or her contact with
the child ren and right to make decision s for the children .)
[ ] This parent does not have any of t hese problems. ( Skip to 4.)
[ ] This parent has one o r more of t hese problems as follows (check all that apply ):
[ ] Abandonment – S/he intentionally abandoned a child listed i n 2 for an
extended time.
[ ] Neglect – S/he substantially refused to perform his/her parenting duties for a
child listed in 2.
[ ] Child Abuse – S/he (or someone living in his/her home) abused or threatened
to abuse a child. The abuse was (check all that apply): [ ] physical [ ] sexual
[ ] repeated emotional abuse.
[ ] Domestic Violence – S/he (or someone living in h is/her home) has a history of
domestic violence as defined in RCW 26.50.010 .
[ ] Assault – S/he (or someone living in his/her home) has assaulted or sexually
assaulted someone causing grievous physical harm or fear of such harm.
[ ] Sex Offense –
[ ] S/he has been convicted of a sex offense as an adult.
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 3 of 14
[ ] Someone living in this parent’s home has been convicted as an adult or
adjudicated as a juvenile of a sex offense.
[ ] Other (specify):
4. Limitations on visitation
a. (Parent ’s name):
[ ] Does not apply. There are no reasons for limitations checked in 3.a. above. (Skip
to 4.b.)
[ ] Because of the limiting factors checked in 3. a. above , this parent has visitation as
follows (check all that apply ):
[ ] No visitation with the chil dren.
[ ] Limited visitation a s shown in the Parents’ Visitation Schedule (5 – 8) below.
[ ] Limited visitation a s follows (specify schedule , list all contact here instead of in
a Parents’ Visitation Schedule , skip sections 5 – 8):
[ ] Supervise d visitation . All visits shall be supervised. Any costs of supervision
must be paid by (name) :
The supervisor shall be:
[ ] a professional supervisor (name) :
[ ] a non -professional supervisor (name) :
The dates and times of supervised contact wi ll be:
[ ] as shown in the Parents’ Visitation Schedule (sections 5 – 8) below.
[ ] as follows (specify) :
(Specific rules for supervision, if any) :
[ ] Other limitations or conditions during visitation (specify) :
[ ] Evaluation or t reatment required. This parent must:
[ ] be evaluated for: .
[ ] start (or continue) and comply with treatment:
[ ] as recommended by the evaluation.
[ ] as follows (specify kind of treatment and any other details ):
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 4 of 14
[ ] provide a copy of the evaluation and compliance reports (specify details):
If this parent does not follow the evaluation or treatment requirements above , then
(what happens) :
[ ] No limitations despite reasons. Despite the limiting factors checked in 3.a.
above , the re should be no limitations or conditions on this parent’s visitation because
the limiting factors do not involve a sex offense and (check one or more ):
[ ] the parent’s past conduct checked above did not affect the children.
[ ] contact with the child ren will not cause them physical, sexual, or emotional
harm, and it is so unlikely that the parent will behave in a harmful or abusive
way again that it is not in the children’s best interest to limit visitation.
b. (Parent ’s name):
[ ] Does not apply . There are no reasons for limitations checked in 3.b. above. (Skip
to Parents’ Visitation Schedule. )
[ ] Because of the limiting factors checked in 3. b. above , this parent has visitation as
follows (check all that apply):
[ ] No visitation with th e children.
[ ] Limited visitation a s shown in the Parents’ Visitation Schedule (5 – 8) below.
[ ] Limited visitation a s follows (specify schedule , list all contact here instead of in
a Parents’ Visitation Schedule , skip sections 5 – 8):
[ ] Sup ervised visitation . All visits shall be supervised. Any costs of supervision
must be paid by (name) :
The supervisor shall be:
[ ] a professional supervisor (name) :
[ ] a non -professional supervisor (name) :
The dates and times of supervised cont act will be:
[ ] as shown in the Parents’ Visitation Schedule (sections 5 – 8) below.
[ ] as follows (specify) :
(Specific rules for supervision, if any) :
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 5 of 14
[ ] Other limitations or conditions during visitation (specify) :
[ ] Evaluation or treatment required. This parent must:
[ ] be evaluated for: .
[ ] start (or continue) and comply with treatment:
[ ] as recommended by the evaluation.
[ ] as follows (specify kind of treatment and any other details ):
[ ] provide a copy o f the evaluation and compliance reports (specify details):
If this parent does not follow the evaluation or treatment requirements above , then
(what happens) :
[ ] No limitations despite reasons. Despite the limiting factors checked in 3. b.
abov e, there should be no limitations or conditions on this parent’s visitation because
the limiting factors do not involve a sex offense and (check one or more ):
[ ] the parent’s past conduct checked above did not affect the children.
[ ] contact with the children will not cause them physical, sexual, or emotional
harm, and it is so unlikely that the parent will behave in a harmful or abusive
way again that it is not in the children’s best interest to limit visitation.
Parents’ Visitation Schedule
Check one:
[ ] Skip the parents’ visitation schedule in sections 5 - 8 if both parent s ha ve no contact with
the children other than what is described in section 4 – Limitations.
The children live with the Petitioner/s except as described in section 4.
[ ] Complete the parents’ visitation schedule in sections 5 - 8.
5. School Schedule
a. Children under School -Age
[ ] Does not apply . A ll children are school -age.
[ ] The schedule for children under school -age is the same as for school -age children.
[ ] Children under school -age will live with Petitioner/s except when they are scheduled
to be with a parent.
Parent (name): ’s visitation schedule is
(check all that apply):
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 6 of 14
[ ] WEEKENDS: [ ] every week [ ] every other week [ ] other (specify) : _____
from (day) at : .m. to (day) at : .m.
from (day) at : .m. to (day) at : .m.
[ ] OTHER (specify) :
Parent (name): ’s visitation schedule is
(check all that apply):
[ ] WEEKENDS : [ ] every week [ ] every other week [ ] other (specify) :
from (day) at : .m. to (day) at : .m.
from (day) at : .m. to (day) at : .m.
[ ] OTHER (specify) :
[ ] Other (specify) :
b. School -Age Children
This schedule will apply (check one):
[ ] immediately.
[ ] when t he youngest child enters (check one): [ ] Kindergarten [ ] 1st grade
[ ] when the oldest child enters (check one): [ ] Kindergarten [ ] 1st grade
[ ] Other:
The children will live with the Petitioner/s except when they are scheduled to be with a
parent.
Parent (name): ’s visitation schedule is
(check all that apply):
[ ] WEEKENDS: [ ] every week [ ] every other week [ ] other (specify) :
from (day) at : .m. to (day) at : .m.
from (day) at : .m. to (day) at : .m .
[ ] OTHER (specify) :
Parent (name): ’s visitation schedule is
(check all that apply):
[ ] WEEKENDS : [ ] every week [ ] every other week [ ] other (specify) :
from (day) at : .m. to (day) at : .m.
from (day) at : .m. to (day) at : .m.
[ ] OTHER (specify) :
[ ] Other (specify) :
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 7 of 14
6. Summer Schedule
Summer begins and ends [ ] according to the school calendar . [ ] as follows:
.
[ ] The Summer Schedule is the same as the School Schedule. (Skip to 7.)
[ ] The Summer Schedule is the same as the School Schedule except that
(name/s): shall spend weeks
of uninterrupted vacation time with the children each summer. The parties shall
confirm their vacation schedules in writing by the end of (date)
each year. (Skip to 7.)
[ ] The Summer Schedule is different than the School Schedule. The Summer Schedule
will begin the summer before :
(check one) : [ ] the youngest child [ ] the oldest child [ ] each child
begins (check one) : [ ] Kindergarten [ ] 1st grade [ ] Other:
During the summer , the children will live with the Petitioner/s except when they are
scheduled to be with a parent.
Parent (name): ’s visitation schedule is
(check all that apply):
[ ] WEEKENDS : [ ] every week [ ] every other week [ ] other (specify) :
from (day) at : .m. to (day) at : .m.
from (day) at : .m. to (day) at : .m.
[ ] OTHER (specify) :
Parent (name): ’s visitation schedule is
(check all that apply):
[ ] WEEKENDS : [ ] every week [ ] every other week [ ] other (specify) :
from (day) at : .m. to (day) at : .m.
from (day) at : .m. to (day) at : .m.
[ ] OTHER (specify) :
7. Holiday Schedule (includes school breaks)
[ ] The Holiday Schedule is the same as the School and Summer Schedules above for all
holidays and school breaks. (Skip to 8.)
[ ] This is the Holiday Schedule for [ ] all children [ ] school -age children only .
The children will be with the Petitioner/s for all holidays and school breaks except as
listed below . (Put one parent ’s name in each column and fill out when the children will
be with that p arent for holiday s and school break s.)
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 8 of 14
Holiday Children w ith (name) : Children w ith (name):
Martin Luther
King Jr. Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] With the person who has the children for the attached weekend
[ ] Other plan :
Presidents’
Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] With the person who has the children for the attached weekend
[ ] Other plan :
Mid -win ter
Break
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Each person has the children for the half of the break attached to his/he r weekend. The
children must be exchanged on Wednesday at (time): .
[ ] Other plan :
Spring Break
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Each person has the children for the half of the break attached to his/her weekend. The
children must be exchanged on Wednesday at (time): .
[ ] Other plan :
Mother’s Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Other plan :
Memorial
Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] With the person who has the children for the attached weekend
[ ] Other plan :
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 9 of 14
Holiday Children w ith (name) : Children w ith (name):
Father’s Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin d ay/time: Begin day/time:
End day/time: End day/time:
[ ] Other plan :
Fourth of
July
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End da y/time:
[ ] Follow the Summer Schedule in section 6.
[ ] Other plan :
Labor Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] With the person who has the children for the attached weekend
[ ] Other plan :
Thanksgiving
Day / Break
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/ti me: End day/time:
[ ] Other plan :
Winter Break
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Other plan :
Christmas
Eve
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Follow the Winter Break schedule above.
[ ] Other plan :
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 10 of 14
Holiday Children w ith (name) : Children w ith (name):
Christmas
Day
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Follow the Winter Break schedule above.
[ ] Other plan :
New Year’s
Eve / New
Year’s D ay
(odd/even is
based on New
Year’s Eve )
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Follow the Winter Break schedule above.
[ ] Other plan :
Children’s
Birthdays
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Other plan :
All three -day
weekends
not li sted
elsewhere
(Federal holidays, school in -service days, etc.)
[ ] The children shall spend any unspecified holiday or non -school day with the person who has
them for the attached weekend.
[ ] Other plan :
Other
occasion
important to
the family:
_________
[ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Other plan :
Other
occasion
important to
the family:
_________
[ ] Odd Yea rs [ ] Even Y ear s [ ] Every Y r. [ ] Odd Y ea rs [ ] Even Y ear s [ ] Every Y r.
Begin day/time: Begin day/time:
End day/time: End day/time:
[ ] Other plan :
8. Conflicts in Scheduling
The Holiday Schedule must be observed over all ot her schedules . If there are conflicts
within the Holiday Schedule (check all that apply) :
[ ] Named holidays shall be followed before school breaks.
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 11 of 14
[ ] Child ren ’s birthdays shall be followed before named holidays and school breaks.
[ ] Other (spec ify):
9. Transportation Arrangements
The children will be exchanged for visitation (picked up and dropped off) at:
[ ] each party’s home .
[ ] school or day care when in session .
[ ] other location (specify) : .
Who is responsible for arranging transportation ?
[ ] The picking up party – The person who is about to start time with the children
must arrange to have the children pick ed up .
[ ] The dropping off party – The person whose time is ending must arrange to have
the children drop ped off .
[ ] All transportation will be arranged by (name): .
Other details (if any) :
10. Moving with the Children (Relocation)
Anyone with majority or substantially equal residential time (at least 45 percent) who
wants to move with the children must no tify every other person who has court -ordered
time with the children .
Move to a different school district
If the move is to a different school district, the custodian must complete the form Notice of
Intent to Move with Children (FL Relocate 701) and del iver it at least 60 days before the
intended move.
Exceptions:
If the custodian could not reasonably have known enough information to complete
the form in time to give 60 days’ notice, the custodian must give notice within 5 days
after learning the infor mation.
If the custodian is relocating to a domestic violence shelter or moving to avoid a
clear, immediate and unreasonable risk to health or safety, notice may be delayed
21 days .
If information is protected under a court order or the address confidenti ality program,
it may be withheld from the notice.
A custodian who believes that giving notice would put her/himself or a child at
unreasonable risk of harm, may ask the court for permission to leave things out of
the notice or to be allowed to move withou t giving notice. Use form Motion to Limit
Notice of Intent to Move with Children (Ex Parte) (FL Relocate 702).
The Notice of Intent to Move with Children can be delivered by having someone personally
serve the other party or by any form of mail that requi res a return receipt.
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 12 of 14
If the custodian wants to change the Parenting Plan because of the move, s/he must
deliver a proposed Parenting Plan together with the Notice .
Move within the same school district
If the move is within the same school district, th e custodian still has to let the other parent
know. However, the notice does not have to be served personally or by mail with a return
receipt. Notice to the other party can be made in any reasonable way. No specific form is
required.
Warning! If you d o not notify…
A custodian who does not give the required notice may be found in contempt of court. If
that happens , the court can impose sanctions. Sanctions can include requiring the
custodian to bring the children back if the move has already happened, and ordering the
custodian to pay the other side’s costs and lawyer’s fees.
Right to object
A person who has court -ordered time with the children can object to a move to a different
school district and/or to the custodian’s proposed Parenting Plan . If the move is within the
same school district, t he other party doesn’t have the right to object to the move, but s/he
may ask to change the Parenting Plan if there are adequate reasons under the
modification law (RCW 26.09.260).
An objection is made by filin g the Objection about Moving with Children and Petition about
Changing a Parenting/Custody Order (Relocation) (form FL Relocate 721). File your
Objection with the court and serve a copy on the custodian and anyone else who has
court -ordered time with the children. Service of the Objection must be by personal service
or by mailing a copy to each person by any form of mail that requires a return receipt. The
Objection must be filed and served no later than 30 days after the Notice of Intent to Move
with Ch ildren was received.
Right to move
During the 30 days after the Notice was served, the custodian may not move to a different
school district with the children unless s/he has a court order allowing the move.
After the 30 days, if no Objection is filed, the custodian may move with the children without
getting a court order allowing the move.
After the 30 days, if an Objection has been filed , the custodian may move with the children
pending the final hearing on the Objection unless :
The other party gets a court order saying the children cannot move, or
The other party has scheduled a hearing to take place no more than 15 days after
the date the Objection was served on the custodian. However, the custodian may
ask the court for an order allowing the mov e even though a hearing is pending if the
custodian believes that s/he or a child is at unreasonable risk of harm.
The court may make a different decision about the move at a final hearing on the Objection .
Parenting Plan after move
If the custodian serve d a proposed Parenting Plan with the Notice , and if no Objection is
filed within 30 days after the Notice was served (or if the parties agree):
Both parties may follow that proposed plan without being held in contempt of the
Parenting Plan that was in plac e before the move. However, the proposed plan
cannot be enforced by contempt unless it has been approved by a court.
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 13 of 14
Either party may ask the court to approve the proposed plan. Use form Ex Parte
Motion for Final Order Changing Parenting Plan – No Obje ction to Moving with
Children (FL Relocate 706).
Forms
You can find forms about moving with children at:
The Washington State Courts’ website: www.courts.wa.gov/forms ,
The Administrative Office of the Courts – call: (360) 705 -5328,
Washington LawHelp: www .washingtonlawhelp.org , or
The Superior Court Clerk’s office or county law library (for a fee).
(This is a summary of the law. The complete law is in RCW 26.09.430 through 26.09.480.)
11. Other
12. Proposal
[ ] Does not apply. This is a court or der.
[ ] This is a proposed (requested) residential schedule . ( The person /s requesting this
schedule must read and sign below. )
I declare under penalty of perjury under the laws of the state of Washington that this
schedule was proposed in good faith and the information in section 3 above is true.
Person requesting schedule signs here Signed at (city and state)
Other p erson requesting sched. (if agreed) signs here Signed at (city and state)
13. Court Order
[ ] Does not apply. This is a proposal.
[ ] This is a court order (if signed by a judge or commissioner below) .
Findings of Fact – Based on the pleadings and any other evidence considered:
The Court adopts the statements in section 3 (Reasons for l imiting a parent ’s
visitation ) a s its findings.
[ ] The Court makes additional findings which are:
[ ] contained in an order or findings of fact entered at the same time as this
Residential Schedule .
[ ] attached as Exhibit A as part of this Residential Schedule .
[ ] other:
Con clusions of Law – This Residential Schedule is in the best interest of the children.
[ ] Other:
RCW 26. 10 .160
Mandatory Form (07/201 9)
FL Non -Parent 405
Residential Schedule
(Non -Parent Custody)
p. 14 of 14
Order – The parties must follow th is Residential Schedule .
Date Judge or Commissioner signs here
Warning! If you don’t follow this Residential Sc hedule , the court may find you in contempt (RCW 26.09.160).
You still have to follow this Residential Schedule even if the other party doesn’t.
Violation of residential provisions of this order with actual knowledge of its terms is punishable by contemp t
of court and may be a criminal offense under RCW 9A.40.060(2) or 9A.40.070(2). Violation of this order may
subject a violator to arrest.
If this is a court order, the parties and/ or their lawyers (and any GAL) sign below.
This order (check any that ap ply): This order (check any that apply):
[ ] is an agreement of the parties . [ ] is an agreement of the parties .
[ ] is presented by me . [ ] is presented by me .
[ ] may be signed by the court without notice to me. [ ] may be signed by the court witho ut notice to me.
Petitioner signs here or lawyer signs here + WSBA # Respondent signs here or lawyer signs here + WSBA #
Print Name Date Print Name Date
This order (check any that apply): This order (check any that apply):
[ ] is an agreement of the parties. [ ] is an agreement of the parties.
[ ] is presented by me. [ ] is presented by me.
[ ] may be signed by the court without notice to me. [ ] may be signed by the court without notice to me.
Other party or lawyer signs here + WSBA # Other party or Guardian ad Litem signs here
Print Name Date Print Name Date
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