FOR COURT USE ONLY SUPERVISED VISITATION PROVIDER (Name and Address): TELEPHONE NO: FAX NO. (Optional): E-MAIL ADDRESS (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: 170 Park Avenue MAILING ADDRESS: 191 North First Street CITY AND ZIP CODE: BRANCH: San Jose, California 95113 Park Avenue Courthouse – Family ANNUAL DECLARATION UNDER PENALTY OF PERJURY I, , do hereby declare under penalty of perjury that I and Name of Professional Provider everyone I employ as a provider of Supervised Visitation, meet the qualifications of a provider. Specifically, I and all my employees are 21 years of age or older, have no 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 or my employee is 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; have no conflict of interest as defined in the Standards 5.20(g), agree to adhere to and enforce the court order regarding supervised visitation and provide no "therapeutic" supervision except as described in this Rule. I also agree to meet all safety and security procedures, have the ration of children to provider as described in the Standards of Judicial Administration 5.20 (f) and/or specific court order, have no conflict of interest, maintain and disclose records as described in the Standards of Judicial Administration 5.20 (h), abide by confidentiality standards and, additionally, meet all of Standards as set forth in Standards of Judicial Administration 5.20. This publication is attached and available on the Court’s website at www.sccsuperiorcourt.org I hereby declare that I meet all the Standards described in Standards of Judicial Administration 5.20 and will continue to do so. Name of Provider: Address of Provider: Name of Signatory: Signature of Signatory: Date: Please send completed original form to: FM-1043 REV 09/02/09 Superior Court of California, County of Santa Clara Attn: Family Court Services 191 North First Street, San Jose, CA 95113 ANNUAL DECLARATION UNDER PENALTY OF PERJURY Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com