SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA Family Court Services 201 North First Street, San José, CA 95113 (408) 534-5760 Mailing Address: 191 North First Street, San José, CA 95113 Petitioner Non-Litigated Your Name: Your Age: Address: City State Zip Code Respondent Joined Party FCS #: Case #: FC #: I do not speak English or Spanish and know I must bring my own interpreter. Dept #: Relationship to Child: Date of Birth: Other last names used: Residence Phone: ( Driver's License #: ) State: Work Phone: ( ) Social Security #: Black/African American Other: Latino/Hispanic Race/Ethnicity (check all that apply): Native American/Eskimo/Aleut Subject to Indian Child Welfare Act Currently Employed: Work Days & Hours: Your attorney: Address: Yes No Asian/Pacific Islander White (non-Latino/Hispanic) Occupation: Employer: Phone: ( City State ) Zip Code Name of other parent in this case: First & Last Name LIST ALL CHILDREN WHO ARE THE SUBJECTS OF THIS ACTION Age Birth Date Sex School Grade Resides with Children's Attorney: Name of Joined Party in this case: Name Phone: ( ) LIST ALL OTHERS RESIDING WITH YOU Age Date of Birth Sex Relationship to You If you plan to move in the next 6 months, when? If you have another case in FCS, name of other parent: Are there any child abuse/neglect issues? If yes, explain briefly: Yes No where? Name & phone number of any involved social worker: If yes, has there been a Welfare and Institution Code §300 Petition filed in Juvenile Dependency Court? Yes No Current Past If yes, which child(ren)? Yes Yes No (name/phone) No Does the child have a juvenile probation officer? Are there drug or alcohol issues in this case? If yes, explain briefly: Has a guardianship been filed? Yes Yes No No Which state(s)/counties? Criminal action pending? What charges? Yes No Case # Yes No Have you been arrested as an adult? What charges? If yes, where? Is there a criminal restraining order in effect? If yes, please attach a copy or bring a copy to your mediation session. FM-1015A REV 07/01/15 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 Marriage Date: Domestic Partnership Date: Date of Last Separation: Date of Final Dissolution: Yes No Dissolution Pending Is there a current custody/visitation order in effect? If yes, please attach a copy of the custody/visitation order or bring a copy to your mediation session. Have you been the victim of domestic violence? Who committed the domestic violence? Other (list name and relationship): Briefly describe the kind of violence and how often it occurred: Yes No The other parent/party When did the most recent violence occur? RIGHT TO SEPARATE SESSIONS: If a party alleging domestic violence in a written declaration under penalty of perjury, or a party protected by a protective order so requests, Family Court Services staff must meet with the parties separately at separate times. (If you have a restraining order of any kind, please attach a copy or bring it with you to your session.) If domestic violence is an issue in a case and both parents wish to be seen together, Family Court Services must still begin all proceedings by interviewing each party separately. Have you attached or are you planning to submit to Family Court Services a copy of the PROTECTIVE ORDER or a WRITTEN DECLARATION UNDER PENALTY OF PERJURY alleging domestic violence? Yes No If you answered "yes," do you wish to be seen separately? Yes No RIGHT TO A SUPPORT PERSON: If the court has issued a PROTECTIVE ORDER, a support person shall be permitted to accompany protected party during any mediation orientation or mediation session, including separate mediation sessions. It is the function of a support person to provide moral and emotional support. The support person is not present as a legal adviser and shall not give legal advice. ˇ ˇ ˇ Yes No Do you have a current PROTECTIVE ORDER? Do you wish to have a support person accompany you in mediation? Have you had a protective order in the past against the other party? Yes Yes No No *** If you stated that you have been a victim of domestic violence, please obtain and complete a separate domestic violence questionnaire from Family Court Services. OTHER SAFETY RELATED ISSUES Please briefly describe any other safety-related issues affecting any party or child named in the proceedings: FEE REQUIREMENTS FOR SCREENINGS, EVALUATIONS, AND GUARDIANSHIPS Fee for above services are $160.00 per hour. ADVANCED DEPOSITS: Screenings require $250.00 each, and Evaluations require $750.00 each in advance. Fees for Non-litigated mediations and for guardianship mediations are $160.00 per person. NO SHOW AND LATE CANCELLATION FEES: ˇ A "NO SHOW" fee of $100.00 will be charged if either or both parties fail to appear (this includes arriving over thirty minutes late). ˇ A "LATE CANCELLATION" fee of $100.00 will be charged if notice of cancellation is less than 48 hours (Mon. ­ Fri.) for mediation appointments, and less than one week (Mon. ­ Fri.) for first Evaluation appointments. Fee rates may be increased in the future at the direction of the Court. Make checks or money orders payable to OFFICE OF THE COURT CLERK. Application for Waiver of Court Fees and Costs are available if you are unable to pay the required fees. Your sworn statement to this effect along with Income and Expense Declarations and required attachments detailing your finances must be submitted to Family Court Services. Unreasonable or frivolous requests for modification of Court fees may result in Court assessed penalties. I understand that any audio, visual or other electronic recording of any communication with Family Court Services staff is prohibited. I declare that the information on this form, including any attachment, is true and correct and that this declaration is executed on (date): Signature FM-1015A REV 07/01/15 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2