Fill and Sign the Myour Names Form

Clerk stamps below when form is filed.JV-296 De Facto Parent Statement1My/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 of4The 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 childfrom: Case Number: (date) to (date) (date) to (date) 6Information 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 writtenreport 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 statusDate: Type or print your name Signature of person requesting de facto parent statusJudicial Council of California‚ JV-296, Page 1 of 1Revised January 1, 2007, Mandatory Form De Facto Parent StatementCal. Rules of Court‚ rule 5.534(e)