FL-324 SUPERVISED VISITATION PROVIDER (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: OTHER PARTY/PARENT: CASE NUMBER: DECLARATION OF SUPERVISED VISITATION PROVIDER 1. nonprofessional provider, As a: professional provider I submit this form to indicate compliance with all applicable requirements for a provider of supervised visitation as defined under Family Code section 3200.5. All of the following requirements are necessary to meet the qualifications under Family Code section 3200.5. I declare that I am a professional provider of supervised visitation and I am paid for providing supervised visitation services as an independent contractor, employee, intern, or volunteer operating independently or through a supervised visitation center or agency and I meet the qualifications under Family Code section 3200.5 as follows (check all that apply): I am 21 years of age or older. I have no record of a conviction 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 a conviction for child molestation, child abuse, or other crimes against a person. I have proof of automobile insurance for transporting the child. I have had no civil, criminal, or juvenile restraining orders within the last 10 years. There is no current or past court order in which I am the person being supervised. I agree to speak the language of the party being supervised and of the child, or I will provide a neutral interpreter over the age of 18 years of age who is able to do so. I agree to adhere to and enforce the court order regarding supervised visitation. I meet the training requirements set forth under Family Code section 3200.5(d). 3. I declare that I am a nonprofessional provider of supervised visitation and I am not being paid to provide supervised visitation services. I meet the qualifications under Family Code section 3200.5 as follows (check all that apply): I have no record of a conviction for child molestation, child abuse, or other crimes against a person. There is no current or past court order in which I am the person being supervised. I agree to adhere to and enforce the court order regarding supervised visitation. I will be transporting the child. I will not be transporting the child. I will be transporting the child and I have proof of automobile insurance. The court has ordered or the parties have stipulated to different qualifications (see attached). 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) 2. SIGNATURE OF DECLARANT Page 1 of 1 NOTICE: See standard 5.20 of the California Standards of Judicial Administration for further requirements that may apply. Form Approved for Optional Use Judicial Council of California FL-324 [New January 1, 2014] DECLARATION OF SUPERVISED VISITATION PROVIDER Family Code § 3200.5 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com