Fill and Sign the Uccjea 497298876 Form

Period of residence to present Address Confidential Person child lived with (name and present address) Relationship to to to to Period of residence to present Address Confidential Person child lived with (name and present address) Relationship to to to––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– FL-105/GC-120 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Mailing Address): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (Name):. SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS CITY AND ZIP CODE: BRANCH NAME CASE NAME: DECLARATION UNDER UNIFO RM CHILD CUSTO DY JURISDICTIO N AND ENFO RCEMENT ACT (UCCJEA) CASE NUMBER: 1. I am a party to this proceeding to determine custody of a child. 2 . My present address is not disclosed. It is confidential under Family Code section 3429. The address of children presently residing with declarant is identified on this declaration as confidential. 3. (Number). minor children are subject to this proceeding as follows: (insert the information requested below. The residence information must be given for the last FIVE years.) a. Child's name Place of birth Date of birth S e x b. Child's name Place of birth Dale of birth S e x Residence information is the same as given above for child a. (If NOT the same, provide the information below.) C . Additional children are listed on Attachment 3c. (Provide requested information for additional children on an attachment.) (Continued on reverse) Form Approved for Optional Use Judicial Council of California FL-105/GC-120 [Rev. January 1, 2007] DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) Family Code, § 3400 et seq. Probate Code, §§ 1510(f), 1512electronic form ã 2006-7 WWW.LawCA.com Law Publishers 6. One or more domestic violence restraining /protective orders are now in effect. (Attach a copy of the orders if you have one.) The orders are from the following court or courts (specify county and state): 7. Do you know of any person who is not a party to this proceeding who has physical custody or claims to have custody of or visitation rights with any child in this case? ––––– ––––– –– ––– –– ––– ––––– ––––– –– ––– –– ––– –– ––– ––––– ––––– ––––– ––––– –––––––––––– ––– –– ––– ––––– –– ––– –– ––– –– ––– –– ––– ––––– ––––– ––––– –– ––– –– ––– ––––– ––––– ––––– –– ––– –– ––– –– ––– –– ––– –– ––– –– ––– –– ––– –– ––– –– ––– ––––– ––––– ––––– ––––– ––––– –– ––– –––––SHORT TITLE: CASE NUMBER: 4. Have you participated as a party or a witness or in some other capacity in another litigation or custody proceeding, in California or elsewhere, concerning custody of a child subject to this proceeding? N o Yes (If yes, provide the following information.) a. Name of each child: b. I was a par ty witnes s other (specify): c. Court (specify name, state, location): d. Court order or judgment (date): 5. Do you have information about a custody proceeding pending in a California court or any other court concerning a child subject to this proceeding, other than that stated in item 4? N o Yes (If yes, provide the following information.) a. Name of each child: b. Nature of proceeding: dissolution or divorce guardianshi p adoptio n other (specify): c. Court (specify name, state, location): d. Status of proceeding: N o Yes (If yes, provide the following information.) a. Name and address of person b. Name and address of person c. Name and address of person Has physical custody Has physical custody Has physical custody Claims custody rights Claims custody rights Claims custody rights Claims visitation rights Claims visitation rights Claims visitation rights Name of each child Name of each child Name of each child I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dat e: . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) 7 . Number of pages attached after this page: NOTICE TO DECLARANT: You have a continuing duty to inform this court if you obtain any information about a custody proceeding in a California court or any other court concerning a child subject to this proceeding. FL--105/GC-120 [Rev. January 1, 2007] DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) P age t wo