SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT Domestic Relations Branch _________________________________ PRINT PLAINTIFF’S NAME _______DRB ___________ PLAINTIFF, v. _________________________________ PRINT DEFENDANT’S NAME DEFENDANT. ATTACHMENT B REQUIRED INFORMATION FOR CUSTODY I, _________________________________, am the PRINT YOUR NAME PLAINTIFF DEFENDANT in this case. 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 the biological or adoptive parent. I am the caretaker. My relationship to the child(ren) is:_________________________ (e.g. grandparent, brother, aunt, etc.). Other: ______________________________________________________________. DC Bar Pro Bono Program (revised 1.2011) Attachment B (Custody) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 3. The other party’s relationship to the child(ren) in this case: [CHECK ONE] The other party is the biological or adoptive parent. The other party is the caretaker. His/Her relationship to the child(ren) is: _________________________ (e.g. grandparent, brother, aunt, etc.). Other: ______________________________________________________________. 4. This Court has the authority 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(es) 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 have 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). 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. DC Bar Pro Bono Program (revised 1.2011) Attachment B (Custody) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 5. The minor child(ren) currently live(s) at the following address(es) with the following peron(s): [USE ONLY ONE ENTRY FOR MULTIPLE CHILDREN LIVING AT THE SAME ADDRESS] Child(ren)’s Name(s) Current Address Since What Date Child(ren) Live(s) With (names) 6. Over the last five years, the child(ren) has/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) 7. 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(s) DC Bar Pro Bono Program (revised 1.2011) Current Address(es) Attachment B (Custody) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 8. I state the following about other cases involving the child(ren): [CHECK ONE] There are no other cases concerning custody of, or visitation with, the child(ren), and there are no other cases that could affect this proceeding. The following cases concern custody of, or visitation with, the child(ren), or could affect this proceeding (e.g. divorce, child support, domestic violence, neglect, etc.) COURT CASE NO. CASE TYPE DATE OF DETERMINATION ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 9. I was I 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 the well-being of the minor child(ren), and I believe that it is in the best interest of the minor child(ren) that I be awarded: [CHECK ONE] joint legal custody 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 minor 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 sole physical custody visitation 12. The presumption in favor of joint custody does not apply in this case because: [CHECK ALL THAT APPLY] There has been domestic violence. There has been child abuse. There has been child neglect. There has been parental kidnapping. AND/OR Joint custody is not in the best interest of the child(ren). DC Bar Pro Bono Program (revised 1.2011) Attachment B (Custody) Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 13. 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 14. I state the following about child support: [CHECK ONE] I am I am not seeking child support on behalf of the child(ren). Respectfully Submitted, ____________________________________ SIGN YOUR NAME DC Bar Pro Bono Program (revised 1.2011) Attachment B (Custody) Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com