FL-326 EVALUATOR (Name and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: DECLARATION OF PRIVATE CHILD CUSTODY EVALUATOR REGARDING QUALIFICATIONS 1. I, (name): to the truth of the facts in this declaration. 2. On (date): CASE NUMBER: , declare that if I appeared in court and were sworn, I would testify , I was appointed by the court to perform a child custody evaluation in this case. 3. I submit this form to indicate compliance with all applicable requirements for a private child custody evaluator under rule 5.225 of the California Rules of Court at the time of my appointment to this case. . LICENSING REQUIREMENTS 4. a. b. c. I am licensed as a psychologist, marriage and family therapist, or clinical social worker; I am licensed as a physician and I am a board-certified psychiatrist, or I have completed a residency in psychiatry; or I am not licensed as indicated in 4a or 4b. NOTICE: If item 4c is checked the court may not appoint the person to perform a child custody evaluation in this case unless, under Family Code section 3110.5(d) and rule 5.225(c)(2)(B) of the California Rules of Court, all the following criteria have been met: (1) The court determined that there are no evaluators who meet the licensing requirements who are willing and available, within a reasonable period of time, to perform child custody evaluations; (2) The parties have stipulated that the person may conduct the child custody evaluation; and (3) The court approves the person's appointment. EDUCATION AND TRAINING REQUIREMENTS 5. I have completed: a. b. The basic and advanced domestic violence training requirements under rule 5.225(e); and The 40 hours of education and training requirements under rule 5.225(d). CONTINUING EDUCATION AND TRAINING REQUIREMENTS 6. a. I have recently completed the initial education and training in item 5. I am required to complete the continuing education requirements of rule 5.225(i) by (specify): (within 18 months after completing the initial education and training described in item 5); or I have completed the continuing education and training requirements under rule 5.225(i) within the 12-month period immediately preceding my appointment to this case: (1) (2) 8 hours of update training requirements covering the subjects described in rule 5.225(d) 4 hours of domestic violence update training under rule 5.230 b. Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California FL-326 [Rev. January 1, 2011] DECLARATION OF PRIVATE CHILD CUSTODY EVALUATOR REGARDING QUALIFICATIONS Family Code, §§ 1816, 3110.5; Cal. Rules of Court, rules 5.225, 5.230 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-326 EVALUATOR'S NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: 7. I have complied with the experience requirements for a private child custody evaluator specified in rule 5.225(g) because I participated in the completion of four court-appointed child custody evaluations in the preceding three years. a. b. I independently conducted and completed the child custody evaluations as required in rule 5.225(g)(1)(A); or I materially assisted another evaluator as stated in rule 5.225(g)(1)(B). 8. I have not complied with the experience requirements for child custody evaluators stated in rule 5.225(g)(1). NOTICE: If item 8 is checked, the court may not appoint an evaluator to perform a child custody evaluation unless, under rule 5.225(g)(2), all the following criteria have been met: 1. The court determined that there are no child custody evaluators who meet the experience requirements for child custody evaluators who are willing and available, within a reasonable period of time, to perform child custody evaluations; 2. The parties have stipulated that the person may conduct the evaluation; and 3. The court approves the person's appointment. USE OF INTERNS 9. I intend to use interns to assist with the child custody evaluation in the manner disclosed and agreed to by the parties and attorneys in the case. Each intern will have complied with the criteria of rule 5.225(m) and will work under my supervision at all times. NOTICE Private child custody evaluators must complete this form and file it with the clerk's office no later than 10 days after notification of each appointment and before beginning any work on the child custody evaluation. (Cal. Rules of Court, rule 5.225(l)(1)(B).) 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) FL-326 [Rev. January 1, 2011] DECLARATION OF PRIVATE CHILD CUSTODY EVALUATOR REGARDING QUALIFICATIONS Page 2 of 2