Page 2 of 2 Approved by the Coalition for Court Access
CCA-JP-1020-1049
www.indianalegalhelp.org
WHEREFORE, the undersigned pray that the Court order parenting time consistent with
this Verified Agreed Entry Establishing Parenting Time, and for all other just and proper relief.
I affirm under penalties for perjury that the foregoing representations and
statements are true.
Date: ______________________________ ____________________________________
Petitioner Signature
____________________________________
Printed Name
STATE OF INDIANA
COUNTY OF ______________________
Before me, _______________________________, a notary public in and for
__________________________ County, State of Indiana, personally appeared
_______________________________________ and having been duly sworn upon their oath says
that the facts all alleged in the foregoing instrument are true.
Date: _______________________________ ____________________________________
Notary Public
My Commission Expires ____________________________________________
I affirm under penalties for perjury that the foregoing representations and statements
are true.
Date: ______________________________ ____________________________________
Respondent Signature
____________________________________
Printed Name
STATE OF INDIANA
COUNTY OF ______________________
Before me, _______________________________, a notary public in and for
__________________________ County, State of Indiana, personally appeared
_______________________________________ and having been duly sworn upon their oath says
that the facts all alleged in the foregoing instrument are true.
Date: _______________________________ ____________________________________
Notary Public
My Commission Expires ____________________________________________
SO ORDERED ________________________________________________________________
____________________________________
Judicial Officer
Distribution:
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________