Clerk stamps below when form is filed. JV-296 1 2 3 My/Our name(s): The child's name: Boy Girl De Facto Parent Statement Child's date of birth: Age: Court name and street address: Relationship to child (grandparent, foster parent, etc.): Superior Court of California, County of 4 The child has lived with me from: to (date) (date) (date) to (date) Case Number: 5 I have had responsibility for the day-to-day care of the child from: to (date) (date) (date) to (date) 6 Information the judge should know about my relationship with the child. (This part must be completed). a. Amount of time I spend with the child (daily, weekly, etc.): have d. I have not attended court hearings about the child. have e. I have not sent a written report to the court about the child. b. Activities I do with the child: c. Kinds of information I have about the child that others may not have (medical, educational, behavioral, etc.): 7 I declare under penalty of perjury under the laws of the State of California that the information on this form is true and correct to my knowledge. This means if I lie on this form, I am committing a crime. 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 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 Statement JV-296, Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com