SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: FOR COURT USE ONLY PETITIONER: RESPONDENT: OTHER PARENT CLAIMANT: NON-PROFESSIONAL SUPERVISED VISITATION PROVIDER DECLARATION OF QUALIFICATIONS CASE NUMBER: DEPARTMENT NUMBER: In accordance with Family Code section 3200.5 and section 5.20(c)(1) of the California Standards of Judicial Administration, I declare that: Initial: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. I am 21 years of age or older. I have no convictions for driving under the influence (DUI) within the past five (5) years. I have not been on probation or parole for the last ten (10) years. I have no record of a conviction for child molestation, child abuse, or other crimes against a person. I have proof of automobile insurance if transporting the child. I have no civil, criminal, or juvenile restraining orders issued against me within the last ten (10) years. I have no current or past court order in which I am the person being supervised. I am not financially dependent on the person being supervised. I am not employed by the person being supervised. I am not an employee of the Superior Court of Santa Clara County. I am not in an intimate relationship with the person being supervised. I agree to adhere to and enforce the court order regarding supervised visitation. I have read and reviewed the court order for supervised visitation. I have read the booklet entitled A Guide for the Non-Professional Provider of Supervised Visitation. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Print Name Signature FM-1129 REV 07/01/14 NON-PROFESSIONAL SUPERVISED VISITATION PROVIDER DECLARATION OF QUALIFICATIONS Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com