FL/E-LP-616 Parent-Child Relationship Declaration (Family Code Section 6323) Case Name ___________________________________ I, ___________________________________, declare: (print name of declarant) I am the Case Number________________ father mother and the other party is the father mother of the following child(ren): Date of Birth_________________ Date of Birth_________________ Date of Birth_________________ ______________________________________ ______________________________________ ______________________________________ CHECK THE STATEMENT(S) THAT APPLY TO YOU: 1. 2. _____ _____ I gave birth to (all of) the child(ren). The child(ren) was/were born during marriage/domestic partnership or within 300 days after separation. I/we adopted the child(ren) or are in process of adoption the child(ren). I have/the other party has signed a declaration of paternity. The Juvenile Dependency Court has made a determination that there is a parent-child relationship between the father and the child(ren)/mother and the child(ren). A court has determined paternity in a child support agency case where custody and/or visitation was an issue. I have been determined to be the parent of the child(ren) through a Uniform Parentage Act court order. Current child custody and visitation orders as follows: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:_______________________ ______________________________________________ Signature of Declarant Page 1 FL/E-LP-616 (Revised 09/2015) MANDATORY Parent-Child Relationship Declaration American LegalNet, Inc. www.FormsWorkFlow.com 3. 4. 5. _____ _____ _____ 6. _____ 7. _____ 8. _____ Family Code 6323 www.saccourt.ca.gov