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 IMPERIAL 939 W. Main Street El Centro, CA 92243 PETITIONER: RESPONDENT: CASE NUMBER: PETITION FOR GRANDPARENT VISITATION (Family Code Section 3104) 1. Petitioner(s) is/are a Child's Name a. b. c. d. maternal paternal grandparent(s) of the following minor child(ren): Birthdate Age Gender 2. Petitioner(s) are seeking reasonable visitation rights with the minor child(ren). 3. There is a preexisting relationship between the grandparent(s) and the grandchild(ren) that has created a bond such that visitation is in the best interest of the child(ren). 4. The parents of the child(ren) are currently married, and one or more of the following circumstances exist (mark all that apply): The parents are currently living separately and apart on a permanent or indefinite basis; One of the parents has been absent for more than one month without the other spouse knowing the whereabouts of the absent spouse; One of the parents joins in the petition with the grandparent; The child is not residing with either parent. The child has been adopted by a stepparent. The parents of the child(ren) are divorced. A Judgment of Dissolution of Marriage was entered on ______________, in _______________________ County, case number __________________, or other location ____________________________, case number __________________. 5. Form Approved for Optional Use FL-15 (Adopted 01/01/11, Revised 01/01/12, 01/01/13) Page 1 of 2 PETITION FOR GRANDPARENT VISITATION American LegalNet, Inc. www.FormsWorkFlow.com Petitioner: Respondent: Case Number: 6. 7. 8. The parents of the child(ren) have never been married. The mother of the minor child(ren) is deceased. The father of the minor child(ren) is deceased. 9. Each child named above is currently living with, _________________________________ (state name and relationship to child(ren) in County:_________________________________, State: ______________. 10. A completed Declaration Under Uniform Child Custody Jurisdiction & Enforcement Act � Judicial Council Form (FL-105) is attached. 11. PARENTAL CONSENT TO REQUEST FOR GRANDPARENT VISITATION: I consent to and join in this Petition for Grandparent Visitation. Date: __________________ _______________________________________ Print Name of Parent of Minor Child(ren) _______________________________________ Signature of Parent of Minor Child(ren) Petitioner(s) request(s) that the court grant reasonable visitation with the following children together with such other relief as the court deems just, pursuant to California Family Code Sections 3100, 3102, and 3104. I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct, and that this declaration was signed at______________________________, California. Date: _________________ Signature of Petitioner_____________________________ Print Name: _____________________________________ Date: _________________ Signature of Petitioner _____________________________ Print Name: _____________________________________ Form Approved for Optional Use FL-15 (Adopted 01/01/11, Revised 01/01/12, 01/01/13) Page 2 of 2 PETITION FOR GRANDPARENT VISITATION American LegalNet, Inc. www.FormsWorkFlow.com