FM-1129 REV 07/01/14
NON-PROFESSIONAL SUPERVISED VISITATION PROVIDER
DECLARATION OF QUALIFICATIONS
Page 1 of 1
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
In accordance with Family Code section 3200.5 and section 5.20(c)(1) of the California Standards of Judicial
Administration, I declare that:
Initial:
1. I am 21 years of age or older.
2. I have no convictions for driving under the influence (DUI) within the past five (5) years.
3. I have not been on probation or parole for the last ten (10) years.
4. I have no record of a conviction for child molestation, child abuse, or other crimes against a person.
5. I have proof of automobile insurance if transporting the child.
6. I have no civil, criminal, or juvenile restraining orders issued against me within the last ten (10) years.
7. I have no current or past court order in which I am the person being supervised.
8. I am not financially dependent on the person being supervised.
9. I am not employed by the person being supervised.
10. I am not an employee of the Superior Court of Santa Clara County.
11. I am not in an intimate relationship with the person being supervised.
12. I agree to adhere to and enforce the court order regarding supervised visitation.
13. I have read and reviewed the court order for supervised visitation.
14. I have read the booklet entitled A Guide for the Non-Professional Provider of Supervised Visitation.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
Print Name Signature
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER:
RESPONDENT:
OTHER PARENT CLAIMANT:
FOR COURT USE ONLY
CASE NUMBER:
NON-PROFESSIONAL SUPERVISED VISITATION PROVIDE
R
DECLARATION OF QUALIFICATIONS
DEPARTMENT NUMBER:
201 North First Street, San José, CA 95113
San José, California 95113
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