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DISSOLUTION I – FORMS • 9

TABLE OF FORMS
Sample Form Number
and Brief Description Page
9A: Stages of Dissolution Flow Chart. . . . . . . . . . . . . . . . . . . . . . . 9-3
9B: Legal Steps for a Divorce or Legal Separation (FL-107-INFO) . . . . . . . . 9-5
9C: Family Law Case Cover Sheet (LA-20/FAM020). . . . . . . . . . . . . . . 9-7
9D: Summons (Family Law) and Standard Restraining Orders (FL-110) . . . . . 9-9
9E: 
Proof of Service of Summons (Family Law – Uniform Parentage –
Custody and Support) (FL-115). . . . . . . . . . . . . . . . . . . . . . . . 9-11
9F: Petition — Marriage/Domestic Partnership (Family Law) (FL-100). . . . . . 9-13
9G-1: Child Custody and Visitation Application Attachment (FL-311) . . . . . . . 9-17
9G-2: Additional Provisions ­— Physical Custody Attachment (FL-341(D)) . . . . . 9-19
9H-1: Joint Legal Custody Attachment (FL-341(E)). . . . . . . . . . . . . . . . . 9-21
9H-2: Children’s Holiday Schedule Attachment (FL-341(C)) . . . . . . . . . . . . 9-23
9H-3: Request for Child Abduction Prevention Orders (FL-312) . . . . . . . . . . 9-25
9I-1: Attachment 11c – Health Care Coverage for Spouse. . . . . . . . . . . . 9-27
9I-2: Attachment 11c – Consolidation Attachment. . . . . . . . . . . . . . . . . 9-29
9I-3: Children’s Health Care Attachment. . . . . . . . . . . . . . . . . . . . . . 9-30
9J: 
Declaration Under Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) . . . . . . . . . . . . . . . . . . . . . . . . . 9-31
9K: Response — Marriage, Domestic Partnership (Family Law) (FL-120) . . . . 9-33
9L: Letter to Litigation Coordinator. . . . . . . . . . . . . . . . . . . . . . . . 9-37
9M: 
Letter to Sheriff (Out-of-County or Out-of-State Personal Service
by Sheriff). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-39
9N: Schedule of Assets and Debts . . . . . . . . . . . . . . . . . . . . . . . . 9-43
9O: 
Letter to Client Advising of Need to Discover Information and
Join Pension Plan (also available in Spanish). . . . . . . . . . . . . . . . . 9-47
9Q: Dissolution I Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-49
9R: RFO Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-51
9S: House Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-53
9T: Pension Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-55
9U: 
Letter to Other Party’s Employer Seeking Pension/Retirement
Plan Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-56
9V: Custody and Visitation Handout (also available in Spanish). . . . . . . . . 9-57
9W: Assets & Debts Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-59

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9 • DISSOLUTION I – FORMS

9-2 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9A:  Stages of Dissolution Flow Chart

Harriett Buhai Center For Family Law


Dissolution of Marriage Flow Chart

Disso 1 Response
(Start your case) (Other party already
served you)

Temporary orders
needed?

File Disso 1 File


Response

Serve other party.


Wait 30 days.

Check court file for


Response after 30 days.

Response Filed
No Response Filed (Contested)
(Default)
Disso 2 - Contested PDD
(Prelim Financial Disclosure)
Disso 2 - Default
(Financial Disclosures/
Default Request) Discovery
(Gather evidence/ Research)

Discovery
(Gather evidence/ Disso 2 - Contested FDD
Research) (Final Financial Disclosure)

Trial Prep
Disso 3 - Disso 3 - (Request Trial/Brief/Lists)
Default Default with
(Judgment Prep/ Agreement
Supporting docs) (Judgment Prep)
Trial Setting Conference

Default
Hearing? Trial

Disso 3 - Disso 3 -
Contested Uncontested
(Judgment Prep) (Stip Judgment Prep)
HBCFL Appointment

Non-appointment
Process
Judgment

F:\Document\Publications\Volunteer Manual\2013\2013 Manual Forms\Chapter 9\9A Stages of Dissolution Flow Chart.doc

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9 • DISSOLUTION I – FORMS

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DISSOLUTION I – FORMS • 9

Sample Form 9B:  Legal Steps for a Divorce or Legal Separation (FL-107-INFO)

FL-107-INFO Legal Steps for a Divorce or Legal Separation


STEP 1. Start Your Case
The petitioner (the person who files the first divorce or legal separation forms with the court) fills out and files with the court
clerk at least a Petition—Marriage/Domestic Partnership (form FL-100) and a Summons (form FL-110) and, if there are
children of the relationship, a Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (form FL-105).
The forms needed to start your case and information about filing fees and fee waivers are available at “Filing Your Case,” at
courts.ca.gov/filing.
The court clerk will stamp and return copies of the filed forms to the petitioner.

STEP 2. Serve the Forms
Someone 18 or older–not the petitioner–serves the spouse or domestic partner (called the respondent) with all the forms from
Step 1 plus a blank Response—Marriage/Domestic Partnership (form FL-120) and files with the court a proof-of-service form,
such as Proof of Service of Summons (form FL-115), telling when and how the respondent was served. (To serve means “to give
in the proper legal way.”) For more information, see “Serving Your First Set of Court Forms” at courts.ca.gov/filing.
The respondent has 30 days to file and serve a Response. So, the petitioner must wait 30 days before starting Step 4.

STEP 3. Disclose Financial Information
At the same time as Step 1 or within 60 days of filing the Petition, petitioner must fill out and have these documents served
on the respondent: Declaration of Disclosure (form FL-140), Income and Expense Declaration (form FL-150), Schedule of
Assets and Debts (form FL-142) or Property Declaration (form FL-160), and all tax returns filed by the party in the two years
before serving the disclosure documents. These disclosure documents are not filed with the court.
If the respondent files a Response, he or she must also complete and serve the same disclosure documents on the petitioner
within 60 days of filing the Response.
The 60-day time frame for serving the disclosures may be changed by written agreement between the parties or by court order.
The petitioner and respondent each file a Declaration Regarding Service (form FL-141) with the court saying disclosures
were served. If the respondent does not serve disclosures, the petitioner can still finish the case without them. For more
information, see “Fill Out and Serve Your Financial Declaration of Disclosure Forms” at courts.ca.gov/filing (click on Step 4).

STEP 4. Finish the Divorce or Legal Separation Case in One of Four Ways
 
Respondent does not file a Response (called “default”) Respondent files a Response
   
No Response and NO No Response BUT written Response AND written Response and NO
written agreement: agreement: Petitioner attaches agreement: Either party files agreement: Parties must
Petitioner waits 30 days after the signed and notarized Appearance, Stipulations, and go to trial to have a judge
Step 2 is complete and agreement to the proposed Waivers (form FL-130) and the resolve the issues. See
prepares a proposed Judgment Judgment (form FL-180), proposed Judgment with “Contested Case” at
(form FL-180), together with together with all other needed written agreement attached and courts.ca.gov/contested.
all other needed forms. See forms. See “Default Case with other needed forms. See
“True Default Case” at courts. Written Agreement” at courts. “Uncontested Case” at courts.
ca.gov/truedefault. ca.gov/defaultagree. ca.gov/uncontested.

IMPORTANT NOTICES
The earliest you can be divorced is six months and one day from one of these three dates (whichever occurs first):
(1) the date Respondent was served with the Summons (form FL-110) and Petition (form FL-100), (2) the date the
Response (form FL-120) was filed, or (3) the date Appearance, Stipulations, and Waivers (form FL-130) was filed.
Legal separation has no waiting period. You are NOT divorced or legally separated until the court enters a Judgment in
your case.
If you need court orders for child support, custody, parenting time (visitation), spousal or partner support, restraining
orders, or other issues, file a Request for Order (form FL-300) asking for temporary orders. See “Request for Order
Information” at courts.ca.gov/divorcerequests for more information.
Annulments: See courts.ca.gov/annulment for information about annulments.
You must keep the court and the other party informed of any change in your mailing address or other contact
information. File and serve a Notice of Change of Address or Other Contact Information (form MC-040) on the other
party or his or her attorney to let them know about the change in your contact information.
FL-107-INFO, Page 1 of 2
Legal Steps for a Divorce or Legal Separation
Judicial Council of California, www.courts.ca.gov
Revise January 1, 2015, Optional Form
Cal. Rules of Court, rule 5.83

27th Edition 9-5


9 • DISSOLUTION I – FORMS

Sample Form 9B:  Legal Steps for a Divorce or Legal Separation (FL-107-INFO)

FL-107-INFO Legal Steps for a Divorce or Legal Separation


Do you have a registered domestic partnership? The process for a divorce or legal separation of a domestic
partnership is the same as on page 1. For information about ending your domestic partnership in the superior court, see
courts.ca.gov/filing. To find out if you are eligible to end your domestic partnership through the Secretary of State, see
courts.ca.gov/summdissodp . Note: There may be differences in federal taxes and other issues for domestic
partnerships. Seek advice from an attorney experienced in domestic partner law.
What if you want a legal separation? The process on page 1 is the same, except you will NOT get a Judgment
for legal separation unless both parties agree to a legal separation OR if respondent has not filed a Response. If both
parties agree to be legally separated but do not agree on other issues, the parties must go to trial to have a judge resolve
those issues. You are NOT legally separated until you receive a Judgment signed by the court. For more information, see
“Legal Separation” at courts.ca.gov/legalseparation. AFTER the court enters a judgment for legal separation, if you
decide you want a divorce, you must start a new case to request a divorce and pay another filing fee.

Getting help to resolve divorce or legal separation cases


You may prefer to resolve some or all of the issues in your divorce or legal separation case without having the court
decide for you. You and your spouse or domestic partner can put your agreement in writing and file it in your case. But
your agreement must follow all legal requirements.

Court Services Where can I get help?


z Family Law Facilitators and Self-Help Centers This information sheet gives you only basic information on
help with court forms and instructions. They can the divorce or legal separation and is not legal advice. If you
provide samples of agreements and other want legal advice, ask a lawyer for help. You may also:
information and, in some cases, help with mediation.
z Contact the family law facilitator or self-help center in
z Family Court Services. If you and the other parent your court for information, court forms, and referrals to
already have a family law case and have filed a local legal resources. For more information, see
Request for Order (form FL-300) seeking orders courts.ca.gov/courtresources.
about child custody and visitation (parenting time),
the court will refer you to Family Court Services. z Find a lawyer through a certified lawyer referral service
They provide child custody mediation or child on the State Bar of California's website:
custody recommending counseling to try to help you calbar.ca.gov/LRS or by calling 866-442-2529
both make a parenting plan that is in the best interest (toll-free).
of your child. Note: They cannot help with financial
issues. z Hire a private mediator. For more information about
court and private services, see courts.ca.gov/selfhelp-adr.
z Settlement Conferences. An informal process in htm.
which a judge or an experienced lawyer meets with
the parties and their lawyers to discuss the case and z Find information on the California Courts Online Self-
their positions and suggests a resolution. The parties
Help Center website: courts.ca.gov/selfhelp.
can either agree to the suggestions or use the
suggestions to help in further settlement discussions. z Find free and low-cost legal help (if you qualify) at
lawhelpcalifornia.org.
Private services (which you can hire
to help you resolve your case): z Find information at your local law library or public
library.
z Lawyers. Also called attorneys, lawyers can help
work out agreements between the parties and
represent you at court hearings and trials. What if there is domestic violence?
z Collaborative Lawyers. Lawyers who represent If there is domestic violence or a protective or restraining
each party but do not go to court. They try to reach order, talk to a lawyer, counselor, or mediator before
an agreement. If court is necessary, the parties must making agreements.
hire new lawyers.
For domestic violence help, call the National Domestic
z Mediators. A lawyer or counselor who helps the Violence Hotline: 800-799-7233; TDD: 800-787-3224; or
parties communicate to explore options and reach a 211 (if available in your area).
mutually acceptable resolution.
Rev. January 1, 2015
Legal Steps for a Divorce or Legal Separation FL-107-INFO, Page 2 of 2

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DISSOLUTION I – FORMS • 9

Sample Form 9C:  Family Law Case Cover Sheet (LA-20/FAM020)

NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk's File Stamp

Maria Smith
433 1st Street
Los Angeles, CA 90008

(213)222-5555
ATTORNEY FOR (Name): Petitioner In Pro Per

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES


COURTHOUSE ADDRESS: 111 N. Hill Street

Los Angeles, CA 90012 HBCFL


PETITIONER/PLAINTIFF: Maria Smith

RESPONDENT/DEFENDANT: Jose Smith

FAMILY LAW CASE COVER SHEET CASE NUMBER:

CERTIFICATE OF GROUNDS FOR ASSIGNMENT TO DISTRICT

Case Filing Instructions


This cover sheet is required so that the court can assign your case to the correct court district for filing and hearing. It
satisfies the requirement for a certificate authorizing filing in the district, as set forth in Los Angeles Superior Court
Rules 2(d) and 14.2. It must be completed and submitted to the court along with the original Complaint or Petition in
ALL Family cases filed in any district of the Los Angeles County Superior Court. This form is not required in
Abandonment & Emancipation cases, which are to be filed at Children s Court.

I. Fill in the requested information.


a) Enter address of Petitioner
ADDRESS: CITY: STATE ZIP CODE

433 1st Street Los Angeles CA 90008


b) Enter address of Respondent. DO NOT COMPLETE THIS ITEM IF THIS IS A MINOR S CONTRACT CASE
ADDRESS: CITY: STATE ZIP CODE

3749 Pine Avenue Los Angeles CA 90008


MINOR CHILDREN INVOLVED? X YES HOW MANY? 2 NO

II. Select the correct district:

a. Under Column 1 below, check the one type of action which best describes the nature of this case.
b. In Column 2 below, circle the reason for your choice of district that applies to the type of action you have checked.

Applicable Reason for Choosing District (See Column 2 below)

1. May be filed in Central District. 3. Child resides within the district.


2. District where one or more of the parties reside. 4. District where Petitioner resides.

1 TYPE OF ACTION (Check only one) (Continued) 2 APPLICABLE REASONS (See above)

X A5520 Dissolution of Marriage 1. 2


A5525 Summary Dissolution of Marriage 1. 2
A5521 Dissolution of Domestic Partnership 1. 2
A5530 Nullity of Void or Voidable Marriage 1. 2
A5531 Nullity of Void or Voidable Domestic 1. 2
Partnership

FAM 020 FAMILY LAW CASE COVER SHEET Page 1 of 2


(Rev 11/11) CERTIFICATE OF GROUNDS FOR ASSIGNMENT TO DISTRICT LASC RULE 5.2
LA-F020

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9 • DISSOLUTION I – FORMS

Sample Form 9C:  Family Law Case Cover Sheet (LA-20/FAM090)

Short Title Smith and Smith Case Number

BD354789

A5510 Legal Separation 1. 2

A5511 Legal Separation of Domestic Partnership 1. 2

A6126 Petition for Custody and Support of Minor 1. 2. 3

A6131 Child Support Services Department (CSSD) 1.


Parentage/Support
A6139 Foreign Support Order 1. 2. 3

A6136 Foreign Custody Order 1. 2. 3

A6138 Uniform Interstate Family Support Act (UIFSA) 1. 2. 3


Responding Petition
A6122 Domestic Violence Restraining Order (Civil (Any Court Jurisdiction DV's only)
Harassment use Civil Cover Sheet)

A6600 Habeas Corpus Petition Child Custody 1. 3

A6080 Petition to Establish Parentage / Paternity (Non- 1. 2. 3


governmental)
A6111 Approval of Minor s Contract (6751 Family Code) 1

A6130 Other Family Complaint or Petition (Specify): 1. 2. 3

A6101 Agency Adoption 1. 4

A6102 Independent Adoption 1. 4

A6104 Stepparent Adoption 1. 4

A6103 Adult Adoption 1. 4

A6106 Sole Custody Petition 1. 4

III. Enter address of minor child if known. (DO NOT COMPLETE UNLESS YOU HAVE CIRCLED ITEM 3 AS AN APPLICABLE REASON

ADDRESS: Do not complete if this case falls under Family Code §6751 CITY: STATE ZIP CODE

IV. Enter the information below and sign the certificate.

Certificate / Declaration of Assignment: The undersigned hereby certifies and declares that the above entitled matter is properly filed for
assignment to the Central District of the Los Angles Superior Court under Code of Civil Procedure §392 et seq., 2300 et
seq. of the Family Code, and Rule 2(b), (c), and (d) of this court for reason checked above. I certify and declare under penalty of perjury
under the laws of the State of California that the foregoing is true and correct.

Date: 6/5/07 . Maria Smith


(SIGNATURE OF ATTORNEY/PARTY WITHOUT ATTORNEY)
Maria Smith, Petitioner in Pro Per

FAM 020 FAMILY LAW CASE COVER SHEET Page 2 of 2


(Rev 11/11) CERTIFICATE OF GROUNDS FOR ASSIGNMENT TO DISTRICT LASC RULE 5.2

9-8 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9D:  Summons (Family Law) and Standard Restraining Orders (FL-110)

FL-110
SUMMONS (Family Law) CITACIÓN (Derecho familiar)
NOTICE TO RESPONDENT (Name): Jose Smith FOR COURT USE ONLY
(SOLO PARA USO DE LA CORTE)
AVISO AL DEMANDADO (Nombre):

You have been sued. Read the information below and on the next page.
Lo han demandado. Lea la información a continuación y en la página siguiente.

Petitioner's name is: Maria Smith


Nombre del demandante:
CASE NUMBER (NÚMERO DE CASO):

You have 30 calendar days after this Summons and Tiene 30 días de calendario después de haber recibido la
Petition are served on you to file a Response (form entrega legal de esta Citación y Petición para presentar una
FL-120) at the court and have a copy served on the Respuesta (formulario FL-120) ante la corte y efectuar la
petitioner. A letter, phone call, or court appearance entrega legal de una copia al demandante. Una carta o llamada
will not protect you. telefónica o una audiencia de la corte no basta para protegerlo.
If you do not file your Response on time, the court Si no presenta su Respuesta a tiempo, la corte puede dar
may make orders affecting your marriage or domestic órdenes que afecten su matrimonio o pareja de hecho, sus
partnership, your property, and custody of your bienes y la custodia de sus hijos. La corte también le puede
children. You may be ordered to pay support and ordenar que pague manutención, y honorarios y costos legales.
attorney fees and costs.
For legal advice, contact a lawyer immediately. Get Para asesoramiento legal, póngase en contacto de inmediato
help finding a lawyer at the California Courts Online con un abogado. Puede obtener información para encontrar un
Self-Help Center (www.courts.ca.gov/selfhelp), at the abogado en el Centro de Ayuda de las Cortes de California
(www.sucorte.ca.gov), en el sitio web de los Servicios Legales
California Legal Services website (www.lawhelpca.org),
de California (www.lawhelpca.org) o poniéndose en contacto
or by contacting your local county bar association.
con el colegio de abogados de su condado.

NOTICE—RESTRAINING ORDERS ARE ON PAGE 2: AVISO—LAS ÓRDENES DE RESTRICCIÓN SE


These restraining orders are effective against both ENCUENTRAN EN LA PÁGINA 2: Las órdenes de restricción
spouses or domestic partners until the petition is están en vigencia en cuanto a ambos cónyuges o miembros de
dismissed, a judgment is entered, or the court makes la pareja de hecho hasta que se despida la petición, se emita un
further orders. They are enforceable anywhere in fallo o la corte dé otras órdenes. Cualquier agencia del orden
California by any law enforcement officer who has público que haya recibido o visto una copia de estas órdenes
received or seen a copy of them. puede hacerlas acatar en cualquier lugar de California.
FEE WAIVER: If you cannot pay the filing fee, ask the EXENCIÓN DE CUOTAS: Si no puede pagar la cuota de
clerk for a fee waiver form. The court may order you to presentación, pida al secretario un formulario de exención de
pay back all or part of the fees and costs that the court cuotas. La corte puede ordenar que usted pague, ya sea en
waived for you or the other party. parte o por completo, las cuotas y costos de la corte previamente
exentos a petición de usted o de la otra parte.

1. The name and address of the court are (El nombre y dirección de la corte son):
[SEAL]
Superior Court of California
111 N. Hill Street
111 N. Hill Street
Los Angeles, CA 90012
2. The name, address, and telephone number of the petitioner’s attorney, or the petitioner without an
attorney, are: (El nombre, dirección y número de teléfono del abogado del demandante, o del
demandante si no tiene abogado, son):
Maria Smith
433 First St
Los Angeles, CA 90008
213-222-5555
Date (Fecha): Clerk, by (Secretario, por) , Deputy (Asistente)
Page 1 of 2

Form Adopted for Mandatory Use


Judicial Council of California
SUMMONS Family Code, §§ 232, 233, 2024.7, 2040, 7700;
Code of Civil Procedure, §§ 412.20, 416.60–416.90
FL-110 [Rev. January 1, 2015] (Family Law) www.courts.ca.gov

27th Edition 9-9


9 • DISSOLUTION I – FORMS

Sample Form 9D:  Summons (Family Law) and Standard Restraining Orders (FL-110)

FL-110
STANDARD FAMILY LAW RESTRAINING ORDERS ÓRDENES DE RESTRICCIÓN ESTÁNDAR DE DERECHO
FAMILIAR
Starting immediately, you and your spouse or domestic En forma inmediata, usted y su cónyuge o pareja de hecho
partner are restrained from: tienen prohibido:
1. removing the minor children of the parties from the state 1. llevarse del estado de California a los hijos menores de las
or applying for a new or replacement passport for those partes, o solicitar un pasaporte nuevo o de repuesto para los
minor children without the prior written consent of the hijos menores, sin el consentimiento previo por escrito de la
other party or an order of the court; otra parte o sin una orden de la corte;
2. cashing, borrowing against, canceling, transferring, 2. cobrar, pedir prestado, cancelar, transferir, deshacerse o
disposing of, or changing the beneficiaries of any cambiar el nombre de los beneficiarios de cualquier seguro u
insurance or other coverage, including life, health, otro tipo de cobertura, como de vida, salud, vehículo y
automobile, and disability, held for the benefit of the discapacidad, que tenga como beneficiario(s) a las partes y
parties and their minor children; su(s) hijo(s) menor(es);
3. transferring, encumbering, hypothecating, concealing, or in 3. transferir, gravar, hipotecar, ocultar o deshacerse de
any way disposing of any property, real or personal, cualquier manera de cualquier propiedad, inmueble o
whether community, quasi-community, or separate, without personal, ya sea comunitaria, cuasicomunitaria o separada,
the written consent of the other party or an order of the sin el consentimiento escrito de la otra parte o una orden de
court, except in the usual course of business or for the la corte, excepto en el curso habitual de actividades
necessities of life; and personales y comerciales o para satisfacer las necesidades
de la vida; y
4. creating a nonprobate transfer or modifying a nonprobate 4. crear o modificar una transferencia no testamentaria de
transfer in a manner that affects the disposition of property manera que afecte la asignación de una propiedad sujeta a
subject to the transfer, without the written consent of the transferencia, sin el consentimiento por escrito de la otra
other party or an order of the court. Before revocation of a parte o una orden de la corte. Antes de que se pueda
nonprobate transfer can take effect or a right of eliminar la revocación de una transferencia no
survivorship to property can be eliminated, notice of the testamentaria, se debe presentar ante la corte un aviso del
change must be filed and served on the other party. cambio y hacer una entrega legal de dicho aviso a la otra
parte.
You must notify each other of any proposed extraordinary Cada parte tiene que notificar a la otra sobre cualquier gasto
expenditures at least five business days prior to incurring these extraordinario propuesto por lo menos cinco días hábiles antes
extraordinary expenditures and account to the court for all de realizarlo, y rendir cuenta a la corte de todos los gastos
extraordinary expenditures made after these restraining orders extraordinarios realizados después de que estas órdenes de
are effective. However, you may use community property, restricción hayan entrado en vigencia. No obstante, puede usar
quasi-community property, or your own separate property to propiedad comunitaria, cuasicomunitaria o suya separada para
pay an attorney to help you or to pay court costs. pagar a un abogado que lo ayude o para pagar los costos de la
corte.

NOTICE—ACCESS TO AFFORDABLE HEALTH AVISO—ACCESO A SEGURO DE SALUD MÁS ECONÓMICO:


INSURANCE: Do you or someone in your household need ¿Necesita seguro de salud a un costo asequible, ya sea para usted
affordable health insurance? If so, you should apply for o alguien en su hogar? Si es así, puede presentar una solicitud con
Covered California. Covered California can help reduce the Covered California. Covered California lo puede ayudar a reducir el
cost you pay towards high quality affordable health care. For costo que paga por seguro de salud asequible y de alta calidad.
more information, visit www.coveredca.com. Or call Covered Para obtener más información, visite www.coveredca.com. O llame
California at 1-800-300-1506. a Covered California al 1-800-300-0213.

WARNING—IMPORTANT INFORMATION ADVERTENCIA—IMFORMACIÓN IMPORTANTE


California law provides that, for purposes of division of De acuerdo a la ley de California, las propiedades adquiridas
property upon dissolution of a marriage or domestic por las partes durante su matrimonio o pareja de hecho en
partnership or upon legal separation, property acquired forma conjunta se consideran propiedad comunitaria para
by the parties during marriage or domestic partnership in fines de la división de bienes que ocurre cuando se produce
joint form is presumed to be community property. If either una disolución o separación legal del matrimonio o pareja de
party to this action should die before the jointly held hecho. Si cualquiera de las partes de este caso llega a
community property is divided, the language in the deed fallecer antes de que se divida la propiedad comunitaria de
that characterizes how title is held (i.e., joint tenancy, tenencia conjunta, el destino de la misma quedará
tenants in common, or community property) will be determinado por las cláusulas de la escritura
controlling, and not the community property correspondiente que describen su tenencia (por ej., tenencia
presumption. You should consult your attorney if you conjunta, tenencia en común o propiedad comunitaria) y no
want the community property presumption to be written por la presunción de propiedad comunitaria. Si quiere que la
into the recorded title to the property. presunción comunitaria quede registrada en la escritura de
la propiedad, debería consultar con un abogado.

FL-110 [Rev. January 1, 2015]


SUMMONS Page 2 of 2

(Family Law)

9-10 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9E:  Proof of Service of Summons (Family Law – Uniform Parentage –
Custody and Support) (FL-115)
FL-115
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY
Maria Smith
433 First St
Los Angeles, CA 90008
TELEPHONE NO.: 213-222-5555 FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (Name): In Pro Per
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Los Angeles
STREET ADDRESS: 111 N. Hill Street
MAILING ADDRESS: 111 N. Hill Street
CITY AND ZIP CODE: Los Angeles, CA 90012
BRANCH NAME: Central District HBCFL
PETITIONER: Maria Smith
RESPONDENT: Jose Smith
CASE NUMBER:

PROOF OF SERVICE OF SUMMONS BD123789

1. At the time of service I was at least 18 years of age and not a party to this action. I served the respondent with copies of:
a. X Family Law—Marriage/Domestic Partnership: Petition—Marriage/Domestic Partnership (form FL-100), Summons (form
FL-110), and blank Response—Marriage/Domestic Partnership (form FL-120)
–or–
b. Uniform Parentage: Petition to Establish Parental Relationship (form FL-200), Summons (form FL-210), and blank
Response to Petition to Establish Parental Relationship (form FL-220)
–or–
c. Custody and Support: Petition for Custody and Support of Minor Children (form FL-260), Summons (form FL-210), and
blank Response to Petition for Custody and Support of Minor Children (form FL-270)
and
d. X (1) X Completed and blank Declaration Under (5) Completed and blank Financial Statement
Uniform Child Custody Jurisdiction and (Simplified) (form FL-155)
Enforcement Act (form FL-105)
(6) Completed and blank Property
(2) Completed and blank Declaration of Declaration (form FL-160)
Disclosure (form FL-140) (7) Request for Order (form FL-300), and blank
(3) Completed and blank Schedule of Assets Responsive Declaration to Request for Order (form
and Debts (form FL-142) FL-320)
(4) Completed and blank Income and (8) Other (specify):
Expense Declaration (form FL-150)

2. Address where respondent was served: Indicate address, date, and time
the Respondent was served.

3. I served the respondent by the following means (check proper boxes):


a. X Personal service. I personally delivered the copies to the respondent (Code Civ. Proc., § 415.10)
on (date): at (time):
b. Substituted service. I left the copies with or in the presence of (name):
who is (specify title or relationship to respondent):
(1) (Business) a person at least 18 years of age who was apparently in charge at the office or usual place of
business of the respondent. I informed him or her of the general nature of the papers.
(2) (Home) a competent member of the household (at least 18 years of age) at the home of the respondent. I
informed him or her of the general nature of the papers.
on (date): at (time):
I thereafter mailed additional copies (by first class, postage prepaid) to the respondent at the place where the
copies were left (Code Civ. Proc., § 415.20b) on (date):
A declaration of diligence is attached, stating the actions taken to first attempt personal service.
Page 1 of 2
Form Approved for Optional Use
Judicial Council of California
PROOF OF SERVICE OF SUMMONS Code of Civil Procedure, § 417.10
www.courts.ca.gov
FL-115 [Rev. January 1, 2015] (Family Law—Uniform Parentage—Custody and Support)

27th Edition 9-11


9 • DISSOLUTION I – FORMS

Sample Form 9E:  Proof of Service of Summons (Family Law – Uniform Parentage –
Custody and Support) (FL-115)

FL-115
PETITIONER: Maria Smith CASE NUMBER:

RESPONDENT: Jose Smith BD123789

3. c. Mail and acknowledgment service. I mailed the copies to the respondent, addressed as shown in item 2, by
first-class mail, postage prepaid, on (date): from (city):
(1) with two copies of the Notice and Acknowledgment of Receipt (form FL-117) and a postage-paid return
envelope addressed to me. (Attach completed Notice and Acknowledgment of Receipt (form FL-117).)
(Code Civ. Proc., § 415.30.)
(2) to an address outside California (by registered or certified mail with return receipt requested). (Attach signed
return receipt or other evidence of actual delivery to the respondent.) (Code Civ. Proc., §§ 415.40, 417.20.)
d. Other (specify code section):
Continued on Attachment 3d.

4. Person who served papers


Name: To be completed by the person
Address: who served the Respondent.

Telephone number:
This person is
a. exempt from registration under Business and Professions Code section 22350(b).
b. X not a registered California process server.
c. a registered California process server: an employee or an independent contractor
(1) Registration no.:
(2) County:
d. The fee for service was (specify): $

5. X I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
–or–
6. I am a California sheriff, marshal, or constable, and I certify that the foregoing is true and correct.

To be completed and signed


by the person who served
the Respondent.

Date:

(NAME OF PERSON WHO SERVED PAPERS) (SIGNATURE OF PERSON W HO SERVED PAPERS)

FL-115 [Rev. January 1, 2015] Page 2 of 2


PROOF OF SERVICE OF SUMMONS
(Family Law—Uniform Parentage—Custody and Support)

9-12 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9F:  Petition — Marriage/Domestic Partnership (Family Law) (FL-100)

Maria Smith

433 1st Street


Los Angeles CA 90008
(213)222-5555

Petitioner in Pro Per


Los Angeles
111 N. Hill Street
111 N. Hill Street
Los Angeles 90012
Central District HBCFL
Maria Smith
Jose Smith

x x

x x

x 6/24/2001 12/15/2014
13 6

Ana Smith 1/19/02 14 F


Paul Smith 12/30/10 4 M

27th Edition 9-13


9 • DISSOLUTION I – FORMS

Sample Form 9F:  Petition — Marriage/Domestic Partnership (Family Law) (FL-100)

Maria Smith
Jose Smith

x
x

x
x
x
x x
x

x Child support be made retroactive to the date of filing of this


petitioner pursuant to Family Code 4009.

x x
x x

x
x
1995 Toyota Camry Petitioner

9-14 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9F:  Petition — Marriage/Domestic Partnership (Family Law) (FL-100)

Maria Smith
Jose Smith

x
Bank of America Savings Account #1234, 1999 Nissan Truck, Target credit card
debt, any and all pension, retirement plans, 401ks or other employee benefits
earned during marriage by Respondent, and other assets and debts acquired
during the marriage.

x x
x Maria Rodriguez
x
1. Consolidation of DVPA case; 2. Health Care for Minor Children;
3. Health Care for Spouse.

x 1, 11c2, 11c3.

3/5/2015
Maria Smith Maria Smith

27th Edition 9-15


9 • DISSOLUTION I – FORMS

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9-16 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9G-1:  Child Custody and Visitation Application Attachment (FL-311)

Maria Smith
Jose Smith BD132789

Ana Smith 1/19/00 Maria Smith & Jose Smith Maria Smith
Paul Smith 12/30/10 Maria Smith & Jose Smith Maria Smith

x
x
x Immediately after hearing

x x
Saturday 10 x

Sunday 5 x

x
Wednesday 4 x

Wednesday 8 x

27th Edition 9-17


9 • DISSOLUTION I – FORMS

Sample Form 9G-1:  Child Custody and Visitation Application Attachment (FL-311)

Maria Smith
Jose Smith BD132789

Jose Smith

Beth Smith or person of Petitioner's Choice


x
(562)772-3700

x Jose Smith
x Jose Smith
x 65 Oak St., LA, CA 90012 or future home of Petitioner
x 65 Oak St., LA, CA 90012 or future home of Petitioner

x x

x Los Angeles

x x

x
x
x
x

9-18 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9G-2:  Additional Provisions —


­ Physical Custody Attachment (FL-341(D))

Maria Smith
Jose Smith

x
x x
7
x x x
x x x

x
x
x

x
x
30

x
x x

Mondays, Wednesdays, and Sundays from 7:00 pm to 7:30 pm.

27th Edition 9-19


9 • DISSOLUTION I – FORMS

Sample Form 9G-2:  Additional Provisions —


­ Physical Custody Attachment (FL-341(D))

Maria Smith
Jose Smith

x x
12

x
In emergency situations, each parent is authorized to take any and all
actions necessary to protect the health and welfare of the children,
including but not limited to the consent to emergency surgical procedures
or treatment. The parent authorizing such emergency treatment must notify
the other parent as soon as possible, within 3 hours, of such emergency and
of all procedures or treatment administered to the children.

9-20 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9H-1:  Joint Legal Custody Attachment (FL-341(E))

Maria Smith
Jose Smith
BD354789

x x

x
x
x
x
x
x

x
x
children's primary care physician.

x
x

27th Edition 9-21


9 • DISSOLUTION I – FORMS

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9-22 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9H-2:  Children’s Holiday Schedule Attachment (FL-341(C))

Maria Smith
Jose Smith
BD354789

8
8

Petitioner

Respondent
Petitioner Respondent

Respondent Petitioner

1/19/05 Petitioner Respondent


5/4/07 Respondent Petitioner

3/3/83 Petitioner
11/1/82 Respondent

27th Edition 9-23


9 • DISSOLUTION I – FORMS

Sample Form 9H-2:  Children’s Holiday Schedule Attachment (FL-341(C))

Maria Smith
Jose Smith
BD354789

9-24 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9H-3:  Request for Child Abduction Prevention Orders (FL-312)

Maria Smith
Jose Smith BD354789

Maria Smith
x

x
x
x
The Respondent's mother, father, four brothers, two sisters, and
numerous aunts and uncles live in Mexico.

The Respondent's family owns a successful hotel business in Mexico


and he can easily find a job there. The Respondent also always talks
about how much he misses Mexico and his family.
x

x
x x
x
x

x
x x
x

The Respondent on many occasions has threatened to take our children away
from me so that I will never see them again if I were to leave him. On or
about 1/1/14, I tried to separate from Respondent. He took the kids to
Mexico and did not return until I agreed to take him back.

x
On or about February 2015, the Respondent was arrested and convicted for
spousal battery against me.

27th Edition 9-25


9 • DISSOLUTION I – FORMS

Sample Form 9H-3:  Request for Child Abduction Prevention Orders (FL-312)

Maria Smith
Jose Smith BD354789

x
x

x
x

x
x
x
x

x
Mexico
15
x

3/14/2016 Maria Smith

9-26 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9I-1:  Attachment 11c – Health Care Coverage for Spouse

1 Smith and Smith


Short Title: __________________ Case No. __________________

2 Attachme nt 11c : HEALTH CARE FOR SPOUSE ATTACHMENT

4 Petitioner respectfully requests that this Court order the following relief so that (s/he ) ma y ha ve health

5 care coverage:

7 That Respondent be ordered to provide health care coverage:

8  1. By direct payment each month to the Petitioner payable by wage assignment for the

9 purchase of health care coverage until further order of this Court.

10  2. By payment to Respondent’s employer ea c h month for any and all COBRA

11 coverage available through state and federal laws and thereafter to provide payment for

12 conversion coverage, until further order of this Court.

13  3. By payment to a designated insurance company each month for the purchase of an

14 adequate plan of health insurance for the Petitioner.

15  4. Any amount so ordered may be increased annually by not more than 10% without

16 further hearing or order of the Court, based upon the actual cost of said coverage for the

17 year.

18  5. The Respondent shall pay 50% of all un-reimbursed health care expense s of the

19 Petitioner within 30 days of request made by the Petitioner submitted with written

20 verification of said expense.

21 □ 6.

22

23

24

25

26

27

28
HEALTH CARE ATTACHMENT
F:\Document\Publications\Volunteer Manual\2013\2013 Manual Forms\Chapter 9\9I-1 Health Care Coverage for Spouse.wpd rev.June 1, 2000
Page ______

27th Edition 9-27


9 • DISSOLUTION I – FORMS

This page was intentionally left blank.

9-28 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9I-2:  Attachment 11c – Consolidation Attachment


SHORT TITLE: Smith and Smith CASE NUMBER: ___________

Attachment 11 C 1:
1 Consolidation Request
2 x 1. Domestic Violence Prevention Act (DVPA) Case number BQ456789 be
3 consolidated and merged into this case, and this action should be ordered the lead case.
4 x 2. All orders previously set forth in the aforementioned DVPA case, including but not
5 limited to CLETS orders, custody and visitation orders, support orders, and property control
6 orders, shall be incorporated and shall remain in full force and effect unless explicitly
7 modified by other terms of the Findings and Order After Hearing Judgment.
8 //
9 //
10 //
11 //
12 //
13 //
14 //
15 //
16 //
17 //
18 //
19 //
20 //
21 //
22 //
23 //
24
25
26
27
28

CONSOLIDATION ATTACHMENT

Page ____

27th Edition 9-29


9 • DISSOLUTION I – FORMS

Sample Form 9I-3:  Children’s Health Care Attachment

1 Smith and Smith


Short Title: _____________________ Case No. __________________
2 11c
CHILDREN’S HEALTH CARE ATTACHMENT________________ TO:
3  Petition, Response, or Application for Order
4 □ Findings and Order After Hearing or Judgment
5
6  1. Health insurance coverage for the minor children of the parties shall be maintained
7 Respondent
by the__________________, if available at no or reasonable cost through his/her
8 place of employment or self-employment.
9  2. Both parties shall cooperate in the presentation, collection, and reimbursement of any
10 health-care claims, including insurance coverage information, identification
11 documents, claim forms and other documents and information necessary to utilize
12 coverage for each supported child and to obtain reimbursement for health care
13 services costs incurred for each supported child.
14  3. Respondent
___________________ 50
shall pay _____% of reasonable and necessary health care
15 costs of each supported child not covered by insurance, including but not limited to,
16 all copays, deductibles, medical, pharmaceutical, vision, dental, orthodontic and
17 mental health costs.
18  4. Any reimbursement due from one party to the other under this order or otherwise
19 under Family Code section 4063 shall be paid within 15 days of demand in the
20 manner specified in Family Code section 4063.
21 □ 5. __________________________________________________________________
22 __________________________________________________________________
23 __________________________________________________________________
24 __________________________________________________________________
25 /
26 /
27 /
28 /

CHILDREN’S HEALTH CARE ATTACHMENT


F:\Document\Publications\Volunteer Manual\2012\2012 Manual Forms\Chapter 9\9I-3.wpd Page ______

9-30 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9J:  Declaration Under Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA)
FL-105/GC-120
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY
Mary Smith
105 W. Beverly Blvd.
Los Angeles, CA 90042

TELEPHONE NO.: FAX NO. (Optional):


E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name): Petitioner in pro per
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Los Angeles
STREET ADDRESS: 111 N. Hill Street
MAILING ADDRESS: 111 N. Hill Street
CITY AND ZIP CODE: Los Angeles, CA 90012
BRANCH NAME: Central District
(This section applies only to family law cases.)
HBCFL
PETITIONER: Mary Smith

RESPONDENT: Jose Smith


OTHER PARTY:
(This section apples only to guardianship cases.) CASE NUMBER:

GUARDIANSHIP OF (Name):
Minor
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
1. I am a party to this proceeding to determine custody of a child.
2. My present address and the present address of each child residing with me is confidential under Family Code section 3429 as
I have indicated in item 3.
3. There are (specify number): 2 minor children who 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 Sex
Ana Smith Portland, OR 1/19/96 F
Period of residence Address Person child lived with (name and complete current address) Relationship
105 W. Beverly Blvd Mary Smith Mother
Los Angeles, CA 90042 Same
4/11/09 to present Confidential Confidential
Child's residence (City, State) Person child lived with (name and complete current address)
210 NE 18th Street Mary Smith / Jose Smith Mother/
1/19/05 to 4/10/09 Portland, OR 97311 105 W. Beverly Blvd / 82 W. 9th St Father
Child's residence (City, State) Person child lived with (name and complete current address)

to
Child's residence (City, State) Person child lived with (name and complete current address)

to
b. Child's name Place of birth Date of birth Sex
Paul Smith Los Angeles, CA 12/30/03 M
x Residence information is the same as given above for child a.
(If NOT the same, provide the information below.)
Period of residence Address Person child lived with (name and complete current address) Relationship

to present Confidential Confidential


Child's residence (City, State) Person child lived with (name and complete current address)

to
Child's residence (City, State) Person child lived with (name and complete current address)

to
Child's residence (City, State) Person child lived with (name and complete current address)

to

c. Additional residence information for a child listed in item a or b is continued on attachment 3c.
d. Additional children are listed on form FL-105(A)/GC-120(A). (Provide all requested information for additional children.) Page 1 of 2
Form Adopted for Mandatory Use Family Code, § 3400 et seq.;
Judicial Council of California DECLARATION UNDER UNIFORM CHILD CUSTODY Probate Code, §§ 1510(f), 1512
FL-105/GC-120 [Rev. January 1, 2009] JURISDICTION AND ENFORCEMENT ACT (UCCJEA)

27th Edition 9-31


9 • DISSOLUTION I – FORMS

Sample Form 9J:  Declaration Under Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA)
FL-105/GC-120
SHORT TITLE: Smith and Smith CASE NUMBER:

4. Do you have information about, or have you participated as a party or as a witness or in some other capacity in, another court case
or custody or visitation proceeding, in California or elsewhere, concerning a child subject to this proceeding?
x Yes No (If yes, attach a copy of the orders (if you have one) and provide the following information):
Court order Your
Proceeding Case number Court or judgment Name of each child connection to Case status
(name, state, location) (date) the case

a. Family

b. Guardianship

c. Other

Proceeding Case Number Court (name, state, location)


d. x Juvenile Delinquency/
Juvenile Dependency CK 123986 Juvenile Court, Monterey Park, CA

e. Adoption

5. One or more domestic violence restraining/protective orders are now in effect. (Attach a copy of the orders if you have one
and provide the following information):

Court County State Case number (if known) Orders expire (date)
a. Criminal

b. Family
Juvenile Delinquency/
c. Juvenile Dependency
d. Other

6. 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? Yes x No (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.
Date: 01/01/09

Mary Smith
(TYPE OR PRINT NAME)
Mary Smith
(SIGNATURE OF DECLARANT)
7. Number of pages attached:

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, 2009] DECLARATION UNDER UNIFORM CHILD CUSTODY Page 2 of 2

JURISDICTION AND ENFORCEMENT ACT (UCCJEA)


9-32 27th Edition
DISSOLUTION I – FORMS • 9

Sample Form 9K:  Response — Marriage, Domestic Partnership (Family Law) (FL-120)

27th Edition 9-33


9 • DISSOLUTION I – FORMS

Sample Form 9K:  Response — Marriage, Domestic Partnership (Family Law) (FL-120)

9-34 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9K:  Response — Marriage, Domestic Partnership (Family Law) (FL-120)

27th Edition 9-35


9 • DISSOLUTION I – FORMS

This page was intentionally left blank.

9-36 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9L:  Letter to Litigation Coordinator

27th Edition 9-37


9 • DISSOLUTION I – FORMS

Sample Form 9L:  Letter to Litigation Coordinator

X
X
X
X

J. Volunteer

9-38 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9M:  Letter to Sheriff (Out-of-County or Out-of-State Personal Service


by Sheriff)

3/1/2015

Sheriff’s Office
1401 Lakeside Drive, 12th Floor
Seattle, WA 22017

Re: Smith and Smith


LASC # BD345789
HBCFL # 2011-107

Dear Sheriff:

We are assisting Maria Smith, who is representing himself/herself in a family law case. The
attached pleadings are sent to you for personal service on: Jose Smith, for whom there is a full
description at the end of this letter.

After serving, please complete the enclosed proof of service. For your convenience we have
indicated the sections you need to complete by affixing stick-on colored dots These include
sections:

Item 2: Address where person was served


Box 3a: Date and Time of service
Item 4: Your full name, address and telephone number.
Box 4 a, b or c: Check the appropriate box.
Items 5 and 6: Check the appropriate box.
Date: Date proof of service was signed
Name: Print your name
Signature: Your signature

Please return the completed proof of service in the enclosed self-addressed stamped envelope
addressed to our office at Harriett Buhai Center for Family Law, 3250 Wilshire Blvd., Suite
710, Los Angeles, CA 90010 within 10 days of receipt of this letter.

If you are required to use your own proof of service, please make sure to indicate the following
otherwise the proof of service will be not be valid and we will have to request you re-complete
the proof of service:

1. Please include the language: “I declare under penalty of perjury under the laws of the
State of California that the foregoing is true and correct.” before the signature of the
person who personally served the court papers. This sentence must be included for the
service to be valid in California. You may declare under penalty of perjury of the laws of
both your state and the State of California.

F:\Document\Publications\Volunteer Manual\Manual Production\2015\2015 Manual Forms\Chapter 9\9M Letter to Sheriff (Out-of-County or


Out-of-State Personal Service by Sheriff).wpd rev. 3/2015 Page 1 of 3

27th Edition 9-39


9 • DISSOLUTION I – FORMS

Sample Form 9M:  Letter to Sheriff (Out-of-Country or Out-of-State Personal Service


by Sheriff)

2. Please list all the following forms on the proof of service as having been served:
X Summons
X Pe tition
X Blank Re sponse
X UCCJEA and Blank UCCJEA
Re que st for Orde r and Supporting De claration
Me morandum of Points and Authoritie s
____ Blank Re sponsive De claration
Income & Expe nse De claration and Blank Income & Expe nse De claration
Financial State me nt (Simplified) and Blank Financial Stateme nt (Simplifie d)
Te mporary Re straining Orde r
Re straining Orde r Afte r He aring
De claration of Disclosure
Sche dule of Asse ts and De bts
Community and Quasi Community Prope rty De claration
____ Se parate Prope rty De claration
Othe r

Should you need any further assistance, please call our office at (213)388-7505/ext. _______ and
identify the case by name and our HB#. Thank you for your anticipated cooperation in this matter.

Sincerely,

J. Volunteer
_____________________
Staff/Volunteer

Page 2 of 3
9-40 27th Edition
DISSOLUTION I – FORMS • 9

Sample Form 9M:  Letter to Sheriff (Out-of-Country or Out-of-State Personal Service


by Sheriff)

INFORMATION NECESSARY FOR SERVICE

Your Name: _________________________ Telephone No.:______________________


Your Address: _________________________________________________________________

PERSON BEING SERVED

Name: Telephone No.: ________________________

Home Address: ________________________________________________________________


City: ____________________ State: _______________ Zip Code: _________

Work Address: ________________________________________________________________


City: ____________________ State: _______________ Zip Code: _________

DESCRIPTION OF PERSON BEING SERVED

Male ( ) Female ( ) Age: ________ Height: ________ Weight: ________

Race
White ( ) Black ( ) Hispanic ( ) Asian ( )

Hair
Color: _______________ Length: _______________ Style: _______________

Facial Hair
Mustache ( ) Beard ( ) Goatee ( ) Bushy Eyebrows ( )

Scars, Marks, Tattoos


Scars ( ) Description: ________________________________________________________
Moles ( ) Description: ________________________________________________________
Tattoos ( ) Description: ________________________________________________________

OTHER IDENTIFYING CHARACTERISTICS OR TRAITS


_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

VEHICLE THEY DRIVE

Car ( ) Truck ( ) Motorcycle ( ) Motor scooter/Bicycle ( )


Year: __________ Make/Model: __________ Color: _____________

Page 3 of 3
27th Edition 9-41
9 • DISSOLUTION I – FORMS

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9-42 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9N:  Schedule of Assets and Debts

THIS FORM SHOULD NOT BE FILED WITH THE COURT FL-142


ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NO.: (213)222-5555
Mary Smith

433 1st Street

Los Angeles, CA 90008


Petitioner in Pro Per
ATTORNEY FOR (Name):
HBCFL
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Los Angeles
111 N. Hill Street, Los Angeles, CA 90010, Central District

PETITIONER: Mary Smith

RESPONDENT: Jose Smith

SCHEDULE OF ASSETS AND DEBTS CASE NUMBER:

X Petitioner's Respondent's
INSTRUCTIONS
List all your known community and separate assets or debts. Include assets even if they are in the possession of another person,
including your spouse. If you contend an asset or debt is separate, put P (for Petitioner) or R (for Respondent) in the first column
(separate property) to indicate to whom you contend it belongs.
All values should be as of the date of signing the declaration unless you specify a different valuation date with the description. For
additional space, use a continuation sheet numbered to show which item is being continued.

SEP. DATE CURRENT GROSS AMOUNT OF MONEY


ITEM ASSETS DESCRIPTION PROP. ACQUIRED FAIR MARKET OWED OR
NO. VALUE ENCUMBRANCE

$ $
1. REAL ESTATE (Give street addresses and attach copies of
deeds with legal descriptions and latest lender's statement.)
None

2. HOUSEHOLD FURNITURE, FURNISHINGS, APPLIANCES


(Identify.)
Household furniture 02/01/96 2,500 1,000
Dishwasher 02/01/96 750 300

3. JEWELRY, ANTIQUES, ART, COIN COLLECTIONS, etc. (Identify.)


Antique clock P 01/1987 50

Page 1 of 4
Code of Civil Procedure, §§ 2030(c), 2033.5
Form Approved for Optional Use
Judicial Council of California
SCHEDULE OF ASSETS AND DEBTS
FL-142 [Rev. January 1, 2005] (Family Law)

27th Edition 9-43


9 • DISSOLUTION I – FORMS

Sample Form 9N:  Schedule of Assets and Debts

SEP. DATE CURRENT GROSS AMOUNT OF MONEY


ITEM PROP. ACQUIRED FAIR MARKET OWED OR
NO. VALUE ENCUMBRANCE
ASSETS DESCRIPTION $ $
4. VEHICLES, BOATS, TRAILERS (Describe and attach copy of title
document.)
None

5. SAVINGS ACCOUNTS (Account name, account number, bank,


and branch. Attach copy of latest statement.)

Bank of America Savings Account 07/1995 100


Account #10056XXXXX

6. CHECKING ACCOUNTS (Account name and number, bank, and


branch. Attach copy of latest statement.)

Bank of America Checking Account 07/1996 500


Account #10053XXXXX

7. CREDIT UNION, OTHER DEPOSIT ACCOUNTS (Account name


and number, bank, and branch. Attach copy of latest statement.)

None

8. CASH (Give location.)


None

9. TAX REFUND
None

10. LIFE INSURANCE WITH CASH SURRENDER OR LOAN VALUE


(Attach copy of declaration page for each policy.)
None

FL-142 [Rev. January 1, 2005] SCHEDULE OF ASSETS AND DEBTS Page 2 of 4

(Family Law)
9-44 27th Edition
DISSOLUTION I – FORMS • 9

Sample Form 9N:  Schedule of Assets and Debts

SEP. DATE CURRENT GROSS AMOUNT OF MONEY


ITEM ASSETS DESCRIPTION PROP. ACQUIRED FAIR MARKET OWED OR
NO. VALUE ENCUMBRANCE

$ $
11. STOCKS, BONDS, SECURED NOTES, MUTUAL FUNDS
(Give certificate number and attach copy of the certificate or
copy of latest statement.)

None

12. RETIREMENT AND PENSIONS (Attach copy of latest summary


plan documents and latest benefit statement.)
Any and all pension, retirement plans 05/1996 unknown
401ks or other employee benefits
earned during marriage by respondent.

13. PROFIT - SHARING, ANNUITIES, IRAS, DEFERRED


COMPENSATION (Attach copy of latest statement.)

None

14. ACCOUNTS RECEIVABLE AND UNSECURED


NOTES (Attach copy of each.)

None

15. PARTNERSHIPS AND OTHER BUSINESS INTERESTS


(Attach copy of most current K-1 form and Schedule C.)

None

16. OTHER ASSETS


None

17. TOTAL ASSETS FROM CONTINUATION SHEET


18. TOTAL ASSETS $ 3,900 $ 1,300
+ unknown
FL-142 [Rev. January 1, 2005]
SCHEDULE OF ASSETS AND DEBTS Page 3 of 4

(Family Law)

27th Edition 9-45


9 • DISSOLUTION I – FORMS

Sample Form 9N:  Schedule of Assets and Debts

ITEM DEBTS SHOW TO WHOM OWED SEP. TOTAL DATE


NO. PROP. OW ING INCURRED

$
19. STUDENT LOANS (Give details.)
None
20. TAXES (Give details.)
None

21. SUPPORT ARREARAGES (Attach copies of orders and statements.)


None
22. LOANS UNSECURED (Give bank name and loan number and attach copy of latest
statement.)
None

23. CREDIT CARDS (Give creditor's name and address and the account number. Attach
copy of latest statement.)
Target 500 01/01/97

24. OTHER DEBTS (Specify):


Loan from Debbie Smith, Petitioner's mother 200 05/01/97

25. TOTAL DEBTS FROM CONTINUATION SHEET

26. TOTAL DEBTS $ 700


NOTE: Client should not complete this
27. (Specify number): pages are attached as continuation sheets. section at Disso I. This form should be
reviewed, dated, signed at Disso II.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

Mary Smith
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

FL-142 [Rev. January 1, 2005]


SCHEDULE OF ASSETS AND DEBTS Page 4 of 4

(Family Law)

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DISSOLUTION I – FORMS • 9

Sample Form 9O:  Letter to Client Advising of Need to Discover Information and
Join Pension Plan (also available in Spanish)

3250 Wilshire Boulevard, Suite 710, Los Angeles, California 90010 213.388.7514
Sponsored by Black Women Lawyers Association of Los Angeles Los Angeles County Bar Association Women Lawyers Association of Los Angeles

Date:

Re: Your Rights to the Pension Plan of your Spouse


HBCFL #: 2006-100

Dear Client :

It has come to our attention that your spouse may have rights to collect a pension at a future date.
As his/her spouse under California law you too may have valuable rights to such pension funds.

In order to protect these rights, you must bring the pension fund into the dissolution action which
you have filed or will be filing. To do this, the pension fund must be served with a special kind
of petition and summons. The action that you take will not negatively affect your spouse's rights
to his/her pension, nor will it affect his/her employment. The petition and summons merely bring
the pension fund into the case so that it can be fairly divided. For the pension fund it only
requires some paperwork. They do not have to come to court.

To protect your rights you must find out and give us the following information about your
spouse's pension:

1. Name and address of employer:

2. Date of hire:

3. Name and address of pension fund:

4. Your spouse's date of birth:

5. Your spouse's identification number in the pension fund:

6. Your spouse's Social Security number:

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27th Edition 9-47


9 • DISSOLUTION I – FORMS

Sample Form 9O:  Letter to Client Advising of Need to Discover Information and
Join Pension Plan (also available in Spanish)

Your Rights to the Pension


Plan of your Spouse
Page 2

7. Name of the labor union representing your spouse:

We suggest you call the Personnel Office at your spouse's employer to get this information. If
you feel you are unable to do this on your own, try to get a friend or relative to help you. You
may also use a form letter to the employer that the Center has prepared for this purpose. You can
ask the staff attorney for a copy of it.

Please provide us with the information requested (numbers 1-7) in writing no later than
.

Please call us at (213) 388-7514 on Fridays from 10:00 a.m. to 12:00 p.m or 2:00 to 4:00 p.m if
you have any questions. Tell us your HBCFL # is .

Very truly yours,

HARRIETT BUHAI CENTER FOR FAMILY LAW


Staff/Volunteer

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9-48 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9Q:  Dissolution I Checklist


FORMS for all cases: Fee Waiver Application and Order, Summons, Petition, Proof of Service,
Family Law Case Cover Sheet, Schedule of Assets and Debts, Blue Confidential Info Form

DISSOLUTION I
Name of Client ___________________________ Date _______________
HB# _________________ Volunteer __________________

1. APPLICATION FOR FEE WAIVER


a. Client Receiving CalWorks, Medi-Cal, food stamps or other public benefit? Y ____ N____
b. Client being supported by a 3rd party? Y _______ N _______
c. Client does not qualify for a fee waiver? _________

2. PETITION
a. Date of Marriage ___________ Date of Se paration ____________(date on which one or
both parties decided marriage was over and one or both acted on that decision)
b. Children? Y _______ N _______
Any born before marriage or after separation? Y _______ N _______
Any children not husband’s biological children? Y _______ N _______
If Yes to either question, do we have a copy of the Birth Certificate? If we don’t yet,
advise Client that we will need a copy before or at next appointment.
c. Custody (See Reverse)
d. Visitation (See Reverse)
e. Property - Community Property - generally all property acquired from the date of marriage until the date
of separation is community property unless by gift or inheritance. Separate Property - all property
acquired before the date of marriage and after the date of separation is separate property.
Only list: 1) property of value (monetary or sentimental) that Client believes the other
side will argue about or
2) property that Client wants to make sure gets divided/assigned.
Also, make sure the property listed is identifiable, e.g. ‘opal and gold ring’, not just ‘ring.’ When
listing bank accounts, do not list entire account number, just last 4 digits for privacy reasons.
Separate Property? Y _______ N _______
Community Property? Y _______ N _______
House? Y _______ N _______
Pension? Y _______ N _______
OTHER IMPORTANT PROPERTY ISSUES? Y _______ N _______
_______________________________________________________________
3. SUPPORT
a. Employment status of spouse: Employed ____ Self-Employed ____ Unknown ____
Incarcerated ____ Unemployed ____ Gov’t Benefits ____
b. If employed, spouse’s employer and work address: ______________________________
_________________________________________________________________
Income estimate:____________________________________________________
How can we prove income? (E.g. paystub, Client’s knowledge of spouse’s earnings)____
______________________________________________________________________
c. If unknown, explain why Client can’t estimate income:__________________________
d. Is there a Child Support (CSSD) case? Y________ N__________
If Yes, what is the case number? ________________________
If Client does not know, tell Client we will need that case number before he next
appointment - she can get the number by calling CSSD
3. SERVICE ISSUES?
Does Client need Posting (because Client has NO way to locate other side)? Y _____ N _____
Does other party live out of state? Y _____ N _____
Is other party in jail/prison? Y____ N_____

4. FOLLOW UP NEEDED? (RFO)


Recent DV or Client fearful of DV? Y _______ N _______
Client being denied access to children? Y _______ N _______
Client fearful that children will be removed from L.A.? Y _______ N _______
Client in need of immediate support orders? Y _______ N _______

27th Edition 9-49


9 • DISSOLUTION I – FORMS

Sample Form 9Q:  Dissolution I Checklist

(Possible) FORMS for cases with kids: UCCJEA, Child Custody and Visitation Attachment, Holiday Schedule,
Additional Provisions, Joint Legal Attachment, Child Abduction Prevention Attachment

Creating an appropriate custody and visitation plan


To help the Client choose a custody and visitation plan, please review the COAS questionnaire and any
pink notes in the file paying attention to issues of domestic violence, child abuse, how the parties appear
to be getting along, how old the children are, where the other parent lives, how long it has been since the
parties lived together with the children, etc.

Please use the following questions to help you and the Client decide on the best Custody and Visitation
plan (please work with the Client to figure out what is in the best interests of the child(ren)
rather than assuming that an every other weekend plan is appropriate)
Please summarize Client’s answers on the lines below:

What’s currently happening in terms of custody and visitation and how long has this been going on?
_________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

How and why did the current schedule develop? E.g. does non-custodial parent choose not to see kids,
does custodial parent prevent him from seeing children, etc. ________________________
____________________________________________________________________________
____________________________________________________________________________

Does this arrangement work? Would Client like to make any changes?____________________
____________________________________________________________________________

What kind of parent is the other party?______________________________________________


_____________________________________________________________________________

Do visits with the children need to be supervised? If yes, Why? __________________________


_____________________________________________________________________________
_____________________________________________________________________________

Does the other party have any problems with drugs or alcohol? __________________________
_____________________________________________________________________________

If there is domestic violence, how can we minimize contact during the exchange of the children?
____________________________________________________________________________
____________________________________________________________________________

Other Issues? _________________________________________________________________


_____________________________________________________________________________

9-50 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9R:  RFO Checklist

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9 • DISSOLUTION I – FORMS

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DISSOLUTION I – FORMS • 9

Sample Form 9S:  House Checklist

HOUSE CHECKLIST

Name of Client: HB #:
Person Completing Form: Date:

Basic Information:
1. Street Address:
City, State and Zip Code:
2. Who lives in the house?  Client  Spouse  Both
a. What date did the client or spouse move out of the house? ___________________
3. Who is paying the mortgage?  Client  Spouse  Other _______________________
4. No. of minor children living in the house?
5. Client wants to  Stay  Leave  Sell
6. Spouse wants to  Stay  Leave  Sell
7. Are any rooms being rented?  Yes  No By whom?
a. Monthly rental income: $
8. Are payments current and being paid?  Yes  No
9. Foreclosure proceeding pending?  Yes  No (If Yes, get referral info from Staff Atty)
Purchase Information:
1. Date of Purchase:
2. Purchase Price: $
3. Amount of down payment: $
4. What was the source of funds for the down payment?
5. Whose name/s were listed on title at time of purchase?
a. How was title taken on the deed - joint tenants, tenants in common, separate property?
6. Have changes been made to who is listed on title since the date of purchase?  Yes  No
a. How is titles held currently?
b. Explain:_____________________________________________________________________
7. If client not on title to the home, explain: ____________________________________________
______________________________________________________________________________
Mortgage Information:
1. Monthly payment: $
2. Does this include taxes & insurance?  Yes  No
3. If answer to #2 is “No” how much are property taxes __________ and (see next page)
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9 • DISSOLUTION I – FORMS

Sample Form 9S:  House Checklist

House Checklist
Page 2

homeowner’s insurance ________________________


4. Mortgage company:
5. Total owed today ________________________________
a. Is there now a 2nd loan on property?  Yes  No
b. Monthly payment $______________ c. Mortgage company_____________________
d. Total owed today $ _________________________________
6. Are there any other loans or property?  Yes  No
Refinancing Information:
1. Was the house refinanced?  Yes  No If yes, for get the following information for each refi:
a. Month and year of refinance ___________________________
b. Mortgage company _________________________________
c. Amount of money, if any, received from refinance _____________________________
d. Did title change at time of refinancing? ____________________________________
e. What was refinance money used for?
 remodel house  pay bills  buy car  I don’t know  Other
Additional Information:
1. Did either party use any separate property funds to pay for Improvements to the house
 Yes  No List source of funds: _________________
Describe Improvements: ______________________________________________
2. Present value: $ Basis for estimate:
3. Equity: $ (Present value - total owed today)
4. Borrowing Capacity:
a. Client’s income: Source(s):
b. Other assets:
a. Spouse’s income: Source(s):
b. Other assets:
5. Any other relevant information:

*** After Completion of Form, Ask Staff Attorney to Get a Property Profile***

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DISSOLUTION I – FORMS • 9

Sample Form 9T:  Pension Checklist

Person completing form:


PENSION CHECKLIST Date:

CLIENT INFORMATION
Name: HBC#: LASC#: Date of Birth:

Date of marriage: Date of separation: SSN:

SPOUSE INFORMATION
Name: Current employment status: (please circle)

Address: Employed, if so where:


Phone #:
Date of Birth: Retired, if so when:

SSN: Terminated, if so when:

Health concerns: On disability, is so when:

SPOUSE EMPLOYMENT HISTORY (SINCE DATE OF MARRIAGE)


Employer Dates employed Position/Job Title Wages/Salary Retirement Plan?
Yes/No/Maybe

1. Does Client have any supporting documentation pertinent to spouse’s past or present employment, wages or
retirement plan? E.g. pay slips, retirement plan account statement, etc. If yes, please list and attach all
information provided by Client.

2. Does Client think spouse had or has a retirement plan (for example a pension, 401(k), 403(b) or savings
plan?)? If yes, why?

3. Does Client know the name of any potential retirement plan spouse has? If yes, please list the name(s) below.

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9 • DISSOLUTION I – FORMS
Sample Form 9U:  Letter to Other Party’s Employer Seeking Pension/Retirement
Plan Information

3250 Wilshire Boulevard, Suite 710, Los Angeles, California 90010 213.388.7514
Sponsored by Black Women Lawyers Association of Los Angeles Los Angeles County Bar Association Women Lawyers Association of Los Angeles

Date:

Dear Employer:

This office is assisting , who is representing her/himself in pro per in an


action for dissolution of marriage against your employee, .
Social Security number . Pension benefits earned by your employee
have been identified as a marital asset. As you may be aware, all pensions and similar benefits earned
during the marriage are considered to be community property and are divisible at the time of the final
judgment.

Your help is required in providing the correct name, address and telephone number of the
pension plan. Please indicate this information below and return it to (client name and HB#)
C/O Harriett Buhai Center for Family Law 3250 Wilshire
Blvd., Ste. 710, Los Angeles, CA 90010.

Your prompt reply within five (5) days would be greatly appreciated.

Very truly yours,

Betty L. Nordwind
Executive Director

PLEASE COMPLETE AND RETURN WITHIN FIVE (5) DAYS

The correct, full name of the pension plan is:__________________________________

The mailing address of the pension plan is: ___________________________________

The telephone number of the pension plan is: __________________________________

There are no pension benefits for this employee.

Name of person completing this form: ______________________________________

Date:_______________

9-56 27th Edition

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DISSOLUTION I – FORMS • 9

Sample Form 9V:  Custody and Visitation Handout (also available in Spanish)

3250 Wilshire Boulevard, Suite 710, Los Angeles, California 90010 213.388.7514
Sponsored by Black Women Lawyers Association of Los Angeles Los Angeles County Bar Association Women Lawyers Association of Los Angeles

CUSTODY AND VISITATION

Perhaps the most important part of your papers is the section where you tell the court what you think
the custody and visitation arrangements should be for your children.

Before you fill in this document you should think about where you want your children to live, who
you want them to live with and how much time you want the other parent to spend with the children.
Ask yourself the following questions:

! Who do your children live with now?


! Do your children live in a healthy and loving home?
! Does the other parent drink excessive alcohol, use drugs, or hurt the children in any way?
! How much time does the other parent spend with the children?
! Where does the other parent spend time with the children?
! Would you like the other parent to spend more or less time with the children?
! Do you feel comfortable when the other parent is alone with the children? If not, why?
! Do you think it would be good for the children to spend the night at the other parent's home?

As you think about these issues, you should think about what is best for your children. That is what
the court cares about most.

The words "custody" and "visitation" have very specific meanings for the court which are probably
different from what you think of when you hear "custody" and "visitation."

"Custody"

There are two kinds of custody and you must make a decision about both kinds. The first kind is
LEGAL CUSTODY. Legal custody gives a parent the authority to make decisions about the child's
education, religious upbringing, medical treatment, and other legal decisions. One parent can have
the right to make these legal decisions alone. This is called "sole" legal custody. Or both parents
could make these legal decisions on their own, with or without the other parent’s agreement. This
is called “joint” legal custody. Joint legal custody may be hard for parents if you don’t agree or
communicate well with the other parent about your children.

The second kind of custody is PHYSICAL CUSTODY. Physical custody gives a parent the
authority to live with the children. The child’s primary place of residence may be with one parent.
This is called “sole” physical custody. Or the children may live with both parents for significant
periods of time. This is called “joint” physical custody.

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9 • DISSOLUTION I – FORMS

Sample Form 9V:  Custody and Visitation Handout (also available in Spanish)

"Visitation”

If the children live with one parent most of the time, then the other parent will have the right to spend
time with the children on a regular basis. The court generally calls this time "visitation." The parent
who has the right to visitation may spend a little or a lot of time with the children. You can ask the
court for "reasonable" visitation which means that you and the other parent will work it out
yourselves or the court will decide what is reasonable after listening to you and the other parent.

If you think that there are reasons why the other parent's time with the children should be limited or
you feel that the other parent should not be alone with the children, instead of "reasonable" visitation
you can ask the court to place restrictions. Some possible restrictions are:

! No overnights
! 24 hours notice by telephone before a visit
! No drinking alcohol before or during the other parent's time with the children
! Supervised visitation where someone of your choice is present during the visitation
! A requirement that the other parent not remove the children from the city, county, or state

If you think that the other parent's visits should be monitored or supervised, you need to decide who
will be the supervisor. For example, the supervisor could be your parents, a good friend, a teacher,
someone from your church or community group. If you and the other parent do not get along, or if
the other parent has hit you, thrown things at you, threatens you or forced you to have sex against
your will, you should not be the supervisor. You should pick someone you trust and who will act
responsibly toward your children.

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9-58 27th Edition


DISSOLUTION I – FORMS • 9

Sample Form 9W:  Assets & Debts Chart

27th Edition 9-59

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