SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER RECOMMENDING COUNSELOR FOR COURT USE ONLY (Name and Address): TELEPHONE NO.: Superior Court of California, County of Placer 10820 Justice Center Drive 2501 N. Lake Blvd. P. O. Box 619072 P.O. Box 5669 Roseville, CA 95661-9072 Tahoe City, CA 96145 Petitioner/Plaintiff: Respondent/Defendant: DECLARATION OF PRIVATE CHILD CUSTODY RECOMMENDING COUNSELOR REGARDING QUALIFICATIONS CASE NUMBER: 1. I, (name) : ____________________________________ , declare that if I appeared in court and were sworn, I would testify to the truth of the facts in this declaration. On (date):_______________________ , I was appointed by the court to perform a child custody recommendation in this case. I am licensed as a psychologist, marriage and family therapist, or clinical social worker. I submit this form to indicate compliance with applicable requirements for a private child custody recommending counselor under rule 5.210 and rule 5.230 of the California Rules of Court at the time of my appointment in this case. 2. 3. 4. 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) ____________________________________________________________________________________________________________________________________________ Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-FCS004 Effective 01-01-2014 American LegalNet, Inc. www.FormsWorkFlow.com