SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER FOR COURT USE ONLY 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: STIPULATION AND ORDER FOR PRIVATE CHILD CUSTODY RECOMMENDING COUNSELOR CASE NUMBER: The parties understand and agree that by their signature below they are agreeing to the issuance of an Order by the Court for the appointment of a Private Child Custody Recommending Counselor to mediate the custody and visitation issues pursuant to the provisions of the Family Code sections listed below in item 11 and the Placer County local rules. The term mediation is now called: Child Custody Recommending Counseling. (CCRC) The parties understand that this process is at their own expense. THEREFORE, it is hereby stipulated and agreed to by the parties that they will participate in Private Child Custody Recommending Counseling. 1. Have the parties participated in Family Court Services (FCS) or CCRC before? Yes No If Yes, when and with whom? Is there a current Domestic Violence Restraining Order? (If Yes, attach a copy of the order) Is there an existing court order for custody/visitation? (If Yes, attach a copy of the order) Yes No 2. 3. Yes No 4. Names and birthdates of the child(ren) involved in this CCRC (mediation) DOB: DOB: DOB: Parties agree that Recommending Counselor. F F F M M M 5. will be appointed as the Private Child Custody 6. The Private Child Custody Recommending Counselor may have access to pertinent information, such as: (1) Child Protective Services history; and/or (2) prior Placer Family Court Services CCRC reports, and (3) prior private CCRC reports regarding the above-named child(ren) and shall keep such information confidential as required by law. The Private Child Custody Recommending Counselor may confer with any court-appointed private and/or Family Court Services Child Custody Recommending Counselors, and any court-appointed custody evaluator involved in the case. The CCRC session and resulting report will be performed in accordance with the laws of the State of California, including but not limited to California Rules of Court 5.210, 5.215, California Family Code sections 3177, 3178(a), 3180, 3181(a), 3182, 3183, 3184, and 3185(a) which may be found at www.leginfo.ca.gov/calaw and the Placer County local rules which may be found at 7. 8. ___________________________________________________________________________________________________________________________________________________ Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 1 of 2 Form No. PL-FCS003 Effective 01-01-2014 American LegalNet, Inc. www.FormsWorkFlow.com www.placer.courts.ca.gov. 9. The Private Child Custody Recommending Counselor is authorized to have ex parte communication with counsel for the minor(s) before a recommendation is made pursuant to Family Code only if the parties stipulate or upon the order of the court. % payable by Petitioner and % payable by 10. The parties stipulate to share all fees: Yes Respondent. The Court shall have the ability to reallocate the CCRC fees at a later date: No 11. The CCRC will attach a Declaration of Qualifications to their CCRC report. 12. The parties understand that this agreement will result in a court order and are aware they may consult with an attorney before signing below. 13. The parties declare they have read this Stipulation and Order and fully understand its contents. If either party is not represented by an attorney, his/her signature must be notarized or witnessed by Placer Superior Court staff. It is so agreed: Date: __________ _____________________________ Petitioner _____________________________ Respondent _____________________________ Attorney for Petitioner _____________________________ Attorney for Respondent Date: __________ Date: __________ Date: __________ IT IS SO ORDERED: Date: __________ _____________________________ Judge of the Superior Court ___________________________________________________________________________________________________________________________________________________ Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Page 2 of 2 Form No. PL-FCS003 Effective 01-01-2014 American LegalNet, Inc. www.FormsWorkFlow.com