SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE CHILD CUSTODY EVALUATOR (Name and Address) FOR COURT USE ONLY Telephone No.: E-mail Address: Address: City and Zip Code: Branch: Fax No.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE ANNUAL DECLARATION OF CHILD CUSTODY EVALUATOR QUALIFICATIONS UNDER PENALTY OF PERJURY , (Name of Child Custody Evaluator) declare as follows: 1. I am a duly licensed (check the appropriate box) social worker psychiatrist therapist other (describe) __________________________________________. I have personal knowledge of all matters stated in this declaration. If called to testify, I can and will competently and affirmatively attest thereto. 2. I have performed at least five child custody evaluations within the last three years. 3. I have read and understand the requirements set forth in California Family Code section 3111, California rules of Court, rule 5.230, and Su perior Court for the Co unty of Rive rside ("the cou rt") Local Rule s, rule 5175. I am in compliance with all training required for child custody evaluators pursuant to the foregoing legislation and rules. 4. I am covered by profe ssional liability in surance for acts, errors and omissions made in the performance of my services as a Private Child Custody Ev aluator. I further understand it is my responsibility to main tain said insurance for as long as I remain on the referral list of Private Child Custody Evaluators ("referral list") maintained by the court. I will immediately advise the Mediation Services Manager ("MSM") for the court of any termination of said policy and/or of any lapse or gap in coverage for as long as I remain on the referral list. 5. I will notify the MSM within five (5) court business days of my license being revoked or suspended. In the event I am arrested or have criminal charges brought against me, I will notify the Mediation Services Manager within 5 court days of the arrest or charge. 6. I understand I am required to file Judicial Council form FL-326 (Declaration of Child Custody Evaluator Regarding Qualifications), within 10 days of each appointment by the court to provide services as a Private Child Custody Evaluator. 7. I will submit all evaluation reports in the format indicated by the court. 8. I will file said reports with the court and furnish them to the parties or their attorney(s) of record no later than 10 days prior to any relevant hearing or proceeding. 9. I agree to file a new and updated Declaration with the court each calendar year by January 15th affirming each of the facts, agreements, and understandings made herein in order to remain on the referral list. 10. I understand and agree that the court may remove me from the referral list at any time upon written notification to the address identified on the referral list. Reasons for removal may include, but are not limited to, the following: (a) Failure to remain current on training mandated by California Rules of Court, Riverside County Superior Court Local Rules and Family Code; (b) Submission of work that that does not meet the sta ndards of practice for a p rivate court evaluator per California Rules of Court, Rule 5.230; Failure to submit work in a timely fashion; or (c) Consistent refusal to accept court cases. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct: Name of Evaluator: Signature of Evaluator: Page 1 of 1 $GRSWHG IRU 0DQGDWRU\ 8VH 5LYHUVLGH 6XSHULRU &RXUW 5,)/ >5HY @ ANNUAL DECLARATION OF CHILD CUSTODY EVALUATOR QUALIFICATIONS )DPLO\ &RGH &DO 5XOHV RI &RXUW UXOH /RFDO 5XOH ULYHUVLGHFRXUWVFDJRYORFDOIUPVORFDOIUPVVKWPO American LegalNet, Inc. www.FormsWorkFlow.com