SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER ATTORNEY OR UNREPRESENTED PARTY FOR COURT USE ONLY (Name, State Bar Number, and Address): TELEPHONE NO.: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): 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: NON-PROFESSIONAL VISITATION MONITOR DECLARATION OF QUALIFICATIONS CASE NUMBER: In accordance with section 5.20(c)(1) and (g) of the California Standards of Judicial Administration, I hereby personally acknowledge and declare: Initials _______ 1. I am 21 years of age or older. _______ 2. I have no convictions for driving under the influence (DUI) within the last 5 years. _______ 3. I have not been on probation or parole for the last 10 years. _______ 4. I have no record of a conviction for child molestation, child abuse, or other crimes against a person. _______ 5. I have a current valid driver's license and proof of automobile insurance (if transporting children). _______ 6. I have no civil, criminal, or juvenile restraining orders issued within the last 10 years. _______ 7. I have no current or past court order in which I am the person being supervised. _______ 8. I am not financially dependent on the person being supervised. _______ 9. I am not an employee of the person being supervised. _______ 10. I am not an employee of or affiliated with the Placer Superior Court, unless my employment contract specifically permits me to be a non-professional monitor. _______ 11. I am not in an intimate relationship with the person being supervised. _______ 12. I agree to adhere to and enforce the court order regarding supervised visitation. _______ 13. I have read and understand the handbook entitled "A Guide for the Non-Professional Provider of Supervised Visitation" and agree to abide by it when supervising visits. 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 ____________________________________________________________________________________________________________________________________________________ Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-FCS005 American LegalNet, Inc. Effective 08-12-2013 www.FormsWorkFlow.com