SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RI-FL012 SUPERVISED VISITATION PROVIDER (Name and Address) FOR COURT USE ONLY TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): SUPERVISED VISITATION PROVIDER ANNUAL DECLARATION I (Name of Professional Provider) , do hereby declare under penalty of perjury that I meet the qualifications of a Supervised Visitation Provider. Specifically, I am 21 years of age or older, have no record of conviction for driving under the influence (DUI) within the last 5 years; have not been on probation or parole for the last 10 years; have no record of a conviction for child molestation, child abuse, or other crimes against a person; have proof of automobile insurance if transporting a child; have no civil, criminal, or juvenile restraining orders within the last 10 years; have no current or past court order in which I am being supervised; speak the language of the party being supervised and of the child or have a neutral interpreter over the age of 18 who is able to do so; agree to adhere to and enforce the court order regarding supervised visitation and meet the training requirements stated in 5.20(f). I also agree to meet all safety and security procedures, have the ratio of children to provider as described in the Standards of Judicial Administration 5.20(g) and/or specific court order, have no conflict of interest, maintain and disclose records as described in the Standards of Judicial Administration 5.20(j), abide by confidentiality standards. I have completed the required training outlined in Cal. Fam. Code § 3200.5(d)(1) and, additionally, meet all of standards as set forth in Standards of Judicial Administration 5.20. I hereby declare under penalty of perjury that I meet all the standards described in Standards of Judicial Administration 5.20 and California Family Code §3200.5 and will continue to do so and have registered with TrustLine (http://trustline.org/). Name of Provider: Address of Provider: Name of Signatory: Signature of Signatory: Date: Please send the completed original form, along with the Provider Information Sheet to: Superior Court of California, County of Riverside Attention: Assistant Deputy Executive Officer ­ Family Court Services 4175 Main Street Riverside, CA 92501 Page 1 of 1 Adopted for Mandatory Use Riverside Superior Court RI-FL012 [Rev. 01/01/16] SUPERVISED VISITATION PROVIDER ANNUAL DECLARATION riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com