Clerk stamps below when form is filed. JV-295 De Facto Parent Request The address of any licensed foster family home must remain confidential unless the judge or the foster parent authorizes release of the address. Court clerks should not send this page to the parties without a court order or authorization of the foster parent. (Welf. & Inst. Code, § 308(a).) Court name and street address: 1 My/Our name(s): Superior Court of California, County of My/Our address: City: My/Our phone #: ( 2 ) State: Zip: Case Number: I am/We are asking that I/we be appointed de facto parent(s) of (Child's name): Date: Type or print your name Signature of person requesting de facto parent status Date: Type or print your name Signature of person requesting de facto parent status Date: Type or print attorney's name Signature of attorney (if applicable) Attorney's address: City: Attorney's phone #: ( ) State: Zip: Judicial Council of California, www.courtinfo.ca.gov Revised January 1, 2007, Mandatory Form Cal. Rules of Court, rule 5.534(e) De Facto Parent Request JV-295, Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com