DECLARATION OF CUSTODIAL PARENT - 1 - FCS-501-2016-M Mandatory Form July 2016 I, , make the following statement in connection with the adoption plans for my child. 1. Date of birth: Place of birth: (day, month, year) (city, state) 2. I believe that the non-custodial parent of the child is: (name, including any aliases) (lieve to be the ) 3/ The non-custodial parent lives at: (street address, city, state) (If present address unknown, give any known past addresses.) S/he works for: as a (position or type of work) Give the names and address of any past employers, if known: 3. Is s/he in school? Yes No If Yes, (name of school, city, state) 4. Is s/he in the armed forces Yes No If yes, what branch is he in and where stationed? 5. Do you know where or when the non-custodial parent was born? Yes No If yes, date: Place of birth: (day, month, year/age) (city, state) 9. Is the non-custodial parent married? Yes No 6. Has a court ordered the non-custodial parent to help support the child? Yes No If yes, which court, when, and in what amounts? American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION OF CUSTODIAL PARENT - 2 - FCS-501-2016-M Mandatory Form July 2016 7. Has s/he promised you in writing to help support the child? Yes No If yes, explain: 6. Have you ever refused to take money or items to help with child support expenses from the non-custodial parent? Yes No If yes, explain: 7. Has the non-custodial parent ever written to, spoken to, or visited with the child? Yes No If yes, what did he do, when, and how many times (state in numbers): 7. Have you ever refused to let him write to, speak to, or visit with the child? Yes No If yes, explain: 10. Has s/he offered to take the child into his/her home? Yes No 11. Has the birth father ever acknowledged that he is the father of the child? Yes No If yes, when, where, and in what manner? 12 Did you and the other parent sign a Voluntary Declaration of Paternity? Yes No If yes, when and where was the declaration signed? 16. Has a paternity test been administered to the child and any possible fathers? Yes No If yes, who administered the tests and what were their results? 13. Has the child ever lived with the non-custodial parent rather than with you? Yes No If yes, give dates: From: to: 18. Has any legal action been brought to determine custody or paternity of the child? Yes No If yes, who brought the action, where, and when? American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION OF CUSTODIAL PARENT - 3 - FCS-501-2016-M Mandatory Form July 2016 20. Have you discussed adoption of the child with the non-custodial parent? Yes No 21. Do you think s/he would agree to an adoption if that is what you wished? Yes No 22, The identity of the birth father/mother of the minor child is unknown to me because 23. I am unable to identify the birth father/mother of the minor because 24. Other information: I understand that this information is given to assist the court in the investigation of the Petition to Declare Minor Free and Terminate Parental Rights. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at on (city , state) (date) (Signature) (Printed name of person who witnessed signature) (Address) (Signature of person who witnessed signature of declarant) American LegalNet, Inc. www.FormsWorkFlow.com