ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, and Address) FOR COURT USE ONLY TELEPHONE NUMBER: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NUMBER (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF LASSEN 2610 Riverside Drive Susanville, CA 96130 PETITIONER: RESPONDENT: NON-PROFESSIONAL VISITATION MONITOR DECLARATION OF QUALIFICATIONS CASE NUMBER: I have been assigned as the non-professional visitation monitor in this case. In accordance with section 5.20 (c), (g) and (l)(2) of the California Standards of Judicial Administration, I acknowledge, declare and agree as follows: 1. 2. 3. 4. I am 21 years of age or older. I have no convictions 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 conviction for child molestation, child abuse or other crimes against a person. I have proof of automobile insurance if transporting the child(ren). I have no civil, criminal or juvenile restraining orders issued within the last 10 years. I have no current or past court order in which I am the person being supervised. I am not financially dependent on the person being supervised. I am not an employee of the person being supervised. I am not an employee of or affiliated with the Lassen Superior Court, unless my employment contract specifically permits me to be a non-professional monitor. I am not in an intimate relationship with the person being supervised. I agree to adhere to and enforce the court order regarding supervised visitation. 5. 6. 7. 8. 9. 10. 11. 12. LSC Form 12A Page 1 of 2 Mandatory Form, Effective 01/01/2013 American LegalNet, Inc. www.FormsWorkFlow.com 13. I agree to report suspected child abuse to the appropriate agency designated to receive child abuse reports. I have read and agree to abide by the guidelines as set forth in the Guide for the NonProfessional Provider of Supervised Visitation. 14. 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 LSC Form 12A Page 2 of 2 Mandatory Form, Effective 01/01/2013 American LegalNet, Inc. www.FormsWorkFlow.com