FL-105/GC-120 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER: RESPONDENT: OTHER PARTY: (This section applies only to family law cases.) (This section apples only to guardianship cases.) GUARDIANSHIP OF (Name): Minor CASE NUMBER: DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) 1. I am a party to this proceeding to determine custody of a child. 2. My present address and the present address of each child residing with me is confidential under Family Code section 3429 as I have indicated in item 3. 3. There are (specify number): minor children who are subject to this proceeding, as follows: (Insert the information requested below. The residence information must be given for the last FIVE years.) a. Child's name Place of birth Date of birth Sex Period of residence Address Person child lived with (name and complete current address) Relationship to present Confidential Child's residence (City, State) Confidential Person child lived with (name and complete current address) to Child's residence (City, State) to Child's residence (City, State) to b. Child's name Residence information is the same as given above for child a. (If NOT the same, provide the information below.) Period of residence to present Address Person child lived with (name and complete current address) Relationship Place of birth Date of birth Sex Person child lived with (name and complete current address) Person child lived with (name and complete current address) Confidential Child's residence (City, State) Confidential Person child lived with (name and complete current address) to Child's residence (City, State) to Child's residence (City, State) to c. d. Person child lived with (name and complete current address) Person child lived with (name and complete current address) Additional residence information for a child listed in item a or b is continued on attachment 3c. Additional children are listed on form FL-105(A)/GC-120(A). (Provide all requested information for additional children.) Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California FL-105/GC-120 [Rev. January 1, 2009] DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) Family Code, § 3400 et seq.; Probate Code, §§ 1510(f), 1512 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-105/GC-120 SHORT TITLE: CASE NUMBER: 4. Do you have information about, or have you participated as a party or as a witness or in some other capacity in, another court case or custody or visitation proceeding, in California or elsewhere, concerning a child subject to this proceeding? Yes No (If yes, attach a copy of the orders (if you have one) and provide the following information): Proceeding Case number Court (name, state, location) Court order or judgment (date) Name of each child Your connection to the case Case status a. Family b. c. Guardianship Other Proceeding d. e. 5. Juvenile Delinquency/ Juvenile Dependency Adoption Case Number Court (name, state, location) One or more domestic violence restraining/protective orders are now in effect. (Attach a copy of the orders if you have one and provide the following information): Court County State Case number (if known) Orders expire (date) a. b. c. d. Criminal Family Juvenile Delinquency/ Juvenile Dependency Other 6. Do you know of any person who is not a party to this proceeding who has physical custody or claims to have custody of or Yes No (If yes, provide the following information): visitation rights with any child in this case? a. Name and address of person b. Name and address of person c. Name and address of person Has physical custody Claims custody rights Claims visitation rights Name of each child Has physical custody Claims custody rights Claims visitation rights Name of each child Has physical custody Claims custody rights Claims visitation rights Name of each child 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) 7. Number of pages attached: NOTICE TO DECLARANT: You have a continuing duty to inform this court if you obtain any information about a custody proceeding in a California court or any other court concerning a child subject to this proceeding. FL-105/GC-120 [Rev. January 1, 2009] DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2