BLYTHE 265 N. Broadway, Blythe, CA 92225 HEMET 880 N. State St., Hemet, CA 92543 INDIO 46-200 Oasis St., Indio, CA 92201 RIVERSIDE 4175 Main St., Riverside, CA 92501 RI-FL003 FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): PETITIONER: CASE NUMBER: RESPONDENT: DECLARATION OF NON-PROFESSIONAL SUPERVISED VISITATION PROVIDER (Standard of Judicial Administration – Standard 5.20) In accordance with the Uniform Standards of Practice for Providers of Supervised Visitation 5.20(c)(1) and 5.20(g), I hereby personally acknowledge and declare: (Initials) I understand the Guidelines for a Non-Professional Supervisor, which are as follows: Must be present for all exchanges; Shall not leave the children alone with the supervised parent; Must intervene if the parent discusses the case with the children or acts in a way that upsets the children; Must terminate the visit if the parent disregards instructions from the supervisor; and Make reasonable efforts to assure the safety and welfare of the children and adults during the visitation; I am an adult, 21 years of age, or older; (Initials) I have no convictions for driving under the influence (DUI) within the last 5 years; (Initials) I have not been on probation or parole for the last 10 years; (Initials) I have no record of a conviction for child molestation, child abuse, or other crimes against a person; (Initials) I have proof of automobile insurance if transporting the child(ren); (Initials) I am not in a personal relationship with the person being supervised. (Initials) I have no criminal, or juvenile restraining orders within the last 10 years; (Initials) I have no current or past court order in which I am the person being supervised; (Initials) I am not financially dependent on the person being supervised; (Initials) Page 1 of 2 Approved for Optional Use Riverside Superior Court RI-FL003 [Rev. 08/12/11] DECLARATION OF NON-PROFESSIONAL SUPERVISED VISITATION PROVIDER Standard 5.20 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com PETITIONER: CASE NUMBER: RESPONDENT: I am not an employee of the person being supervised; (Initials) I am not an employee of or affiliated with any Riverside Superior Court unless my employment contract specifically permits me to be a non-professional visitation monitor; and (Initials) I understand my role and the expectations of a Non-Professional Supervised Visitation Provider. I agree to adhere to and enforce the court order regarding supervised visitation. I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Date: (TYPE OR PRINT NAME OF THE PARTY MAKING DECLARATION) (SIGNATURE) Page 2 of 2 Form Adopted for Optional Use Riverside Superior Court RI-FL003 [Rev. 08/12/11] DECLARATION OF NON-PROFESSIONAL SUPERVISED VISITATION PROVIDER Standard 5.20 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com