1.
As a:
I submit this form to indicate compliance with all applicable requirements for a provider of supervised visitation as defined
under Family Code section 3200.5. All of the following requirements are necessary to meet the qualifications under Family
Code section 3200.5.
3.
❐❒❏❆
professional provider
nonprofessional provider,
The court has ordered or the parties have stipulated to different qualifications (see attached).
I have no record of a conviction for child molestation, child abuse, or other crimes against a person.
I will be transporting the child.
There is no current or past court order in which I am the person being supervised.
I agree to adhere to and enforce the court order regarding supervised visitation.
2.
I am 21 years of age or older.
I have no record of a conviction for driving under the influence (DUI) within the last five years.
I have not been on probation or parole for the last 10 years.
I have no record of a conviction for child molestation, child abuse, or other crimes against a person.
I have proof of automobile insurance for transporting the child.
I have had no civil, criminal, or juvenile restraining orders within the last 10 years.
There is no current or past court order in which I am the person being supervised.
I agree to speak the language of the party being supervised and of the child, or I will provide a neutral interpreter
over the age of 18 years of age who is able to do so.
I agree to adhere to and enforce the court order regarding supervised visitation.
I meet the training requirements set forth under Family Code section 3200.5(d).
I declare that I am a professional provider of supervised visitation and I am paid for providing supervised visitation services
as an independent contractor, employee, intern, or volunteer operating independently or through a supervised visitation
center or agency and I meet the qualifications under Family Code section 3200.5 as follows (check all that apply):
I declare that I am a nonprofessional provider of supervised visitation and I am not being paid to provide supervised
visitation services.
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Form Approved for Optional Use
Judicial Council of California
FL-324 [New January 1, 2014]
DECLARATION OF SUPERVISED VISITATION PROVIDER
Family Code § 3200.5
www.courts.ca.gov
For your protection and privacy, please press the Clear
This Form button after you have printed the form.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
(TYPE OR PRINT NAME)
Date:
SIGNATURE OF DECLARANT
u
SUPERVISED VISITATION PROVIDER (Name and address):
TELEPHONE NO.:
FAX NO. (Optional):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARTY/PARENT:
CASE NUMBER:
DECLARATION OF SUPERVISED VISITATION PROVIDER
E-MAIL ADDRESS (Optional):
FL-324
I will be transporting the child and I have proof of automobile insurance.
I will not be transporting the child.
NOTICE: See standard 5.20 of the California Standards of Judicial Administration for further requirements that may apply.
FOR COURT USE ONLY
I meet the qualifications under Family Code section 3200.5 as follows (check all that apply):
