Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Person child lived with (name and complete current address)
Additional children are listed on form FL-105(A)/GC-120(A). (Provide all requested information for additional children.)
FL-105/GC-120
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NUMBER:
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):
(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
Period of residence
Address
Relationship
Confidentialto present
to
to
to
b. Child’s name
Place of birth Date of birth Sex
Residence information is the same as given above for child a.
(If NOT the same, provide the information below.)
Period of residence
Address
Relationship
Confidential
to present
to
to
to
Additional residence information for a child listed in item a or b is continued on attachment 3c.
c.
Page 1 of 2
Family Code, § 3400 et seq.; Form Adopted for Mandatory Use
Judicial Council of California
FL-105/GC-120 [Rev. January 1, 2009]
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
Probate Code, §§ 1510(f), 1512
minor children who are subject to this proceeding, as follows:
www.courtinfo.ca.gov
TELEPHONE NO.:
FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
PETITIONER:
RESPONDENT:
GUARDIANSHIP OF (Name):
Minor
OTHER PARTY:
Child's residence (City, State)
Child's residence (City, State)
Child's residence (City, State)
d.
Child's residence (City, State)
Child's residence (City, State)
Child's residence (City, State)
(This section applies only to family law cases.)
(This section apples only to guardianship cases.)
Confidential
Confidential
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
end of the form when finished.
Juvenile Delinquency/
Juvenile Dependency
and provide the following information):
5. One or more domestic violence restraining/protective orders are now in effect. (Attach a copy of the orders if you have one
a. Criminal
b. Family
d. Other
Court State Case number (if known) County Orders expire (date)
Court
(name, state, location)
Court order
or judgment
(date)
Case status
b. Guardianship
c. Other
Name of each child
a. Family
Case number
Court (name, state, location)
e. Adoption
Juvenile Delinquency/
Juvenile Dependency
Case Number
Your
connection to
the case
CASE NUMBER:
SHORT TITLE:
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?
Yes
(If yes, attach a copy of the orders (if you have one) and provide the following information):
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?
(If yes, provide the following information):Yes
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:
(TYPE OR PRINT NAME) (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
FL-105/GC-120 [Rev. January 1, 2009]
Page 2 of 2
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
4.
6.
No
proceeding in a California court or any other court concerning a child subject to this proceeding.
No
FL-105/GC-120
Proceeding
Proceeding
c.
d.
For your protection and privacy, please press the Clear This Form
button after you have printed the form.
Save This Form
Print This Form
Clear This Form
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