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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY (LawHelp.org)

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SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
FAMILY COURT
Domestic Relations Branch
COMPLAINT FOR THIRD PARTY CUSTODY and/or VISITATION
Action Involving Child Support yes no
I, _________________________________, am the Plaintiff in this case, and I am asking the
PRINT YOUR NAME
Court for [CHECK ONE] custody (I want responsibility for raising the child(ren))
visitation (I want the opportunity to visit with the child(ren))
________________________________________
PRINT YOUR NAME
________________________________________
STREET ADDRESS
________________________________________
CITY, STATE AND ZIP CODE
SUBSTITUTE ADDRESS: CHECK BOX IF YOU
HAVE WRITTEN SOMEONE ELSE’S ADDRESS BECAUSE
YOU FEAR HARASSMENT OR HARM.
PLAINTIFF,
v.
________________________________________
PRINT OTHER PARTY’S NAME
________________________________________
STREET ADDRESS
________________________________________
CITY, STATE AND ZIP CODE
DEFENDANT 1.
________________________________________
PRINT OTHER PARTY’S NAME
________________________________________
STREET ADDRESS
________________________________________
CITY, STATE AND ZIP CODE
DEFENDANT 2.
_______DRB _________________
JUDGE: ______________________
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 1 of 7
1. The child(ren) in this case:
Child’s Full Name Child’s Date of Birth Gender
2. My relationship to the child(ren) in this case:
[CHECK ONE]
I am or seek to be the caretaker. My relationship to the child(ren)
is:______________________ (e.g. grandparent, brother, aunt, etc.).
or
Other _____________________________________________________________.
3. The other party’s/parties’ relationship to the child(ren) in this case:
___________________________________________________: [CHECK ONE]
PRINT FIRST OTHER PARTY’S NAME
The above party is the biological or adoptive parent.
or
The above party is the caretaker. His/Her relationship to the child(ren) is
__________________________. (e.g. grandparent, brother, aunt, etc.)
or
Other _____________________________________________________________.
___________________________________________________: [CHECK ONE]
PRINT SECOND OTHER PARTY’S NAME (IF APPLICABLE)
The above party is the biological or adoptive parent.
or
The above party is the caretaker. His/Her relationship to the child(ren) is
__________________________. (e.g. grandparent, brother, aunt, etc.)
or
Other _____________________________________________________________.
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 2 of 7
4. I have standing to bring this action because: [CHECK ALL THAT APPLY]
The parent who is or has been the primary caretaker of the child within the past 3
years consents to my complaint.
I have lived in the same household as the child for at least 4 of the last 6 months or, if
the child is under the age of 6 months, for at least half of the child's life; and I have
primarily assumed the duties and obligations for which a parent is legally responsible,
including providing the child with food, clothing, shelter, education, financial support,
and other care to meet the child's needs.
I am living with the child and I need custody to prevent harm to the child, because,
[PROVIDE SPECIFIC REASONS]:
Other:
5. This Court is the proper place to decide issues of child custody because: [CHECK ONE]
Home State. The District of Columbia is the child(ren)’s “home state” because the
child(ren) currently live(s) in the District of Columbia AND has/have lived in the District
of Columbia for at least six months immediately before filing this Complaint.
Home State. The child(ren) do not currently live in the District of Columbia, BUT the
District of Columbia was the “home state” AND the child(ren) has/have been away from
the District of Columbia for less than six months before the filing of this Complaint AND
a parent or a person acting as a parent continues to live in the District of Columbia.
Significant Connections. There is no “home state” or the “home state” has declined
to exercise jurisdiction on the grounds that the District of Columbia is the more
appropriate forum AND the child(ren) and at least one parent or person acting as a parent
has a significant connection with the District of Columbia AND there is substantial
evidence available in the District of Columbia concerning the child(ren)’s care,
protection, training and personal relationships.
More Appropriate Court. All courts with jurisdiction have declined to exercise
their jurisdiction in favor of the District of Columbia because this is the more appropriate
Court to determine custody of the child(ren).
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 3 of 7
No Other Court. There is no other court with jurisdiction to determine custody of
the child(ren).
Temporary Emergency Jurisdiction. The District of Columbia is not the “home
state” BUT the child(ren) is/are present in the District of Columbia AND the child(ren)
has/have been abandoned OR it is necessary in an emergency to protect the child(ren)
because the child(ren), or a sibling or parent of the child(ren), is/are subjected to or
threatened with mistreatment or abuse.
6. The minor child(ren) currently live(s) at the following address(es) with the following
person(s): [USE ONLY ONE ENTRY FOR MULTIPLE CHILDREN LIVING AT THE SAME ADDRESS]
Child(ren)’s
Name(s)
Current Address
Since What
Date
Child Lives With
(names)
7. Over the last five years, the child(ren) have lived in the following places, with the
following persons: [USE ONLY ONE ENTRY FOR MULTIPLE CHILDREN WHO PREVIOUSLY LIVED AT THE SAME
ADDRESS]
Child(ren)’s
Name(s)
Previous Address
During What
Dates
Child(ren) Lived With
(name and current address)
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 4 of 7
8. The following people, who are not parties to this case, have physical custody of, or claim
rights of legal or physical custody of, or visitation with the child(ren):
Name Current Address
9.
I was was not a party or witness or participant of any kind in any other
proceeding concerning the custody of or visitation with the child(ren).
10.
Legal Custody. I am a fit and proper person to have legal custody of the minor child(ren)
and make decisions about their well-being, and I believe that it is in the best interest of the minor
child(ren) that I be awarded:
[CHECK ONE]
joint legal custody with: ______________________________________________
PRINT NAME OF PARTY/PARTIES
sole legal custody
11.
Physical Custody. I am a fit and proper person to have physical custody of the minor
child(ren) and to have responsibility and control of the child(ren), and I believe that it is in the
best interest of the minor child(ren) that I be awarded:
[CHECK ONE]
joint physical custody with: _____________________________________________
PRINT NAME OF PARTY/PARTIES
sole physical custody
visitation
12.
I state the following about visitation: [CHECK ALL THAT APPLY]
We can work out a visitation schedule on our own.
We need a specific schedule of visitation
Any visitation should be supervised because _____________________________.
The other party should not receive any visitation because
13.
I state the following about child support: [CHECK ONE]
I am I am not seeking child support on behalf of the child(ren).
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 5 of 7
Request for Relief
I RESPECTFULLY REQUEST that the Court: [CHECK ALL THAT APPLY]
Grant me: sole physical custody
joint physical custody with __________________________________
PRINT NAME OF PARTY/PARTIES
Grant me: sole legal custody
joint legal custody with______________________________________
PRINT NAME OF PARTY/PARTIES
Allow _______________________________________________to visit with the child(ren).
PRINT NAME OF PARTY/PARTIES
Allow only supervised visitation for ____________________________________________.
PRINT NAME OF PARTY/PARTIES
Allow no visitation for _______________________________________________________.
PRINT NAME OF PARTY/PARTIES.
Award child support according to the Child Support Guideline of the District of Columbia
and other applicable laws, including:
current child support (support starting today and continuing into the future)
retroactive child support (support for time before today)
health insurance
Hold a hearing on my request for child support within 45 days of filing
and issue a Notice of Hearing and Order Directing Appearance (“NOHODA”) to the other
party with the date and time of the hearing.
Note that we have a written agreement.
Please: include our written agreement as a part of its order.
do not include our written agreement as a part of its order.
/ I do
do not know of any proceedings in the District of Columbia or in any state or
as this case. Please list sterritory involving the same claim or subject matter as this case. Pl
docket number for cases involving the same claim or subject matter.
Court
Case Number Case Type
14.
I ALSO REQUEST that the Court award any other relief it considers fair and proper.
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 6 of 7
I declare under penalty of perjury that the foregoing is true and correct.
If this document is to be signed outside the geographic boundaries of the United States, Puerto
Rico, the United States Virgin Islands, and any territory or insular possession subject to the
jurisdiction of the United States, additional requirements must be met prior to signing.
See Super. Ct. Dom. Rel. R. 2(c)(1)(B).
____________________________________
SIGN YOUR NAME
____________________________________
PRINT YOUR NAME
____________________________________
HOME ADDRESS 1
____________________________________
HOME ADDRESS 2
SUBSTITUTE ADDRESS: CHECK BOX IF YOU
HAVE WRITTEN SOMEONE ELSE’S ADDRESS
BECAUSE YOU FEAR HARASSMENT OR HARM.
____________________________________
DATE
____________________________________
PHONE NUMBER
____________________________________
EMAIL ADDRESS
DC Bar Pro Bono Center (revised 02/2021)
Complaint for Third Party Custody and/or Visitation - Page 7 of 7
. Add slashes to either side /like this/ to sign electonically.
Pursuant to Superior Court of the District of Columbia Administrative Order 15-14, a party filing a case in the Superior Court shall submit this form with any initial pleading except for a charging document. Any
date of birth, social security number, or driver’s license number provided on the Information Sheet shall be kept confidential, shall not be made part of any public record, and shall be used only for the Superior
Court’s internal business purposes. The Confidential Form shall not be retained in the case file and shall be shredded or otherwise destroyed within a reasonable time after the case is entered into the case
management system. If any identifying information becomes available after the case has been initiated, the party must submit an updated Confidential Form.
Rev. January 11, 2021
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
500 INDIANA AVENUE, NW, WASHINGTON, D.C. 20001
(202) 879-1010 |
https://www.dccourts.gov
CONFIDENTIAL INFORMATION FORM
(This form will be returned to the filer or destroyed immediately
after the information is entered into the Court’s case management system)
Case Caption: _____________________________________________________________ Case No.: _______________________________________
Plaintiff/Petitioner
Defendant/Respondent
Full Name
(First, Middle, Last)
(Month, Day, Year)
Telephone Number(s)
Home: ____________________________________
Cell/Mobile: _______________________________
Work: ____________________________________
Home: ____________________________________
Cell/Mobile: _______________________________
Work: ____________________________________
Ethnicity
☐
Hispanic, Latino/a, or Spanish
☐
Non-Hispanic
☐
Hispanic, Latino/a, or Spanish
☐
Non-Hispanic
Race
Select one or more
☐
American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander
☐ White
☐ Other
☐
American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander
☐ White
☐ Other
Pursuant to Superior Court of the District of Columbia Administrative Order 15-14, a party filing a case in the Superior Court shall submit this form with any initial pleading except for a charging document. Any
date of birth, social security number, or driver’s license number provided on the Information Sheet shall be kept confidential, shall not be made part of any public record, and shall be used only for the Superior
Court’s internal business purposes. The Confidential Form shall not be retained in the case file and shall be shredded or otherwise destroyed within a reasonable time after the case is entered into the case
management system. If any identifying information becomes available after the case has been initiated, the party must submit an updated Confidential Form.
Rev. January 11, 2021
Plaintiff/Petitioner
Defendant/Respondent
Police Department
Identification Number (PDID)
or Taxpayer Identification
Date of Death (if applicable)
Are you a participant of the
Address Confidentiality
Program managed by the Office
of Victim Services
and Justice Grants?
☐YES
☐ NO
Please attach a copy of your Authorization Card to this form. If submitting the confidential form
electronically, please attach your Authorization Card via email.
Interpreter Needed?
Interpreter needed for:
☐ Spanish
☐ Amharic
☐ ASL
☐ Other: ___________________________
☐ No interpreter needed.
Interpreter needed for:
☐ Spanish
☐ Amharic
☐ ASL
☐ Other: ___________________________
☐ No interpreter needed.
ADA or Other Accommodation
Needed?
☐ Assisted Listening Device
☐ Braille
☐ Communication Access Real-time Translation
☐ Court Comfort Dog
☐ Literacy Assistance
☐ Service Animal
☐ Visually Impaired-Large Print
☐ Wheelchair
☐ Other: _______________________________
☐ Assisted Listening Device
☐ Braille
☐ Communication Access Real-time Translation
☐ Court Comfort Dog
☐ Literacy Assistance
☐ Service Animal
☐ Visually Impaired-Large Print
☐ Wheelchair
☐ Other: _______________________________
Pursuant to Superior Court of the District of Columbia Administrative Order 15-14, a party filing a case in the Superior Court shall submit this form with any initial pleading except for a charging document. Any
date of birth, social security number, or driver’s license number provided on the Information Sheet shall be kept confidential, shall not be made part of any public record, and shall be used only for the Superior
Court’s internal business purposes. The Confidential Form shall not be retained in the case file and shall be shredded or otherwise destroyed within a reasonable time after the case is entered into the case
management system. If any identifying information becomes available after the case has been initiated, the party must submit an updated Confidential Form.
Rev. January 11, 2021
DOMESTIC VIOLENCE CASES only
Please indicate if any of the information below is CONFIDENTIAL from the defendant/respondent.
Plaintiff/Petitioner
Defendant/Respondent
If your address is confidential
from respondent, please give a
substitute/safe address where the
court can reach you
Demographics
Race:______________
Sex:_________________
Height:_____________
Weight:______________
Eye Color:__________
Hair Color: ___________
Race:______________
Sex:_________________
Height:_____________
Weight:______________
Eye Color:__________
Hair Color: ___________
Driver’s License Number
(Optional)
Place of Employment and
Address (If applicable)
Additional Questions
Did the police arrest the responent in this case?
☐
Yes
☐
No
When is the best time to serve the other party (when are they there)?______________________ (am/pm)
List any other address to serve Respondent (other than one previously listed) ___________________________
What is the best time to reach you (when are you able to pick up a call)?___________________(am/pm)
Pursuant to Superior Court of the District of Columbia Administrative Order 15-14, a party filing a case in the Superior Court shall submit this form with any initial pleading except for a charging document. Any
date of birth, social security number, or driver’s license number provided on the Information Sheet shall be kept confidential, shall not be made part of any public record, and shall be used only for the Superior
Court’s internal business purposes. The Confidential Form shall not be retained in the case file and shall be shredded or otherwise destroyed within a reasonable time after the case is entered into the case
management system. If any identifying information becomes available after the case has been initiated, the party must submit an updated Confidential Form.
Rev. January 11, 2021
FAMILY COURT CASES only
Plaintiff/Petitioner
Defendant/Respondent
Driver’s License Number
Child’s Name
Name(s) of Child(ren):
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Name(s) of Child(ren):
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Other’s Name and
Relationship
Name: ___________________________________
Relationship:
______________________________
Name: ___________________________________
Relationship:
______________________________
Type of case you are filing
List other cases you have in
this Court
Case Type: __________________________________
Case Number: ________________________________
Case Type: __________________________________
Case Number: ________________________________
List cases you have in
another Court
Case Type: __________________________________
Case Number: ________________________________
Case Type: __________________________________
Case Number: ________________________________
Do you have an attorney?
☐
Yes
☐
No
If “Yes,” what is the attorney’s
name?______________________________
☐
Yes
☐
No
If “Yes,” what is the attorney’s
name?______________________________
Pursuant to Superior Court of the District of Columbia Administrative Order 15-14, a party filing a case in the Superior Court shall submit this form with any initial pleading except for a charging document. Any
date of birth, social security number, or driver’s license number provided on the Information Sheet shall be kept confidential, shall not be made part of any public record, and shall be used only for the Superior
Court’s internal business purposes. The Confidential Form shall not be retained in the case file and shall be shredded or otherwise destroyed within a reasonable time after the case is entered into the case
management system. If any identifying information becomes available after the case has been initiated, the party must submit an updated Confidential Form.
Rev. January 11, 2021
Are you afraid of the party
that you are filing against?
☐
Yes
☐
No
☐
Yes
☐
No
Do you fear for your safety?
☐
Yes
☐
No
☐
Yes
☐
No
If you have children, do you
fear for their safety?
☐
Yes
☐
No
☐
Yes
☐
No
Have you or your children
been hurt, harmed or
threatened to be hurt or
harmed by the other party?
☐
Yes
☐
No
☐
Yes
☐
No
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Completed 13 June 2021

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