VN221 Superior Court of California County of Ventura DECLARATION OF INDIVIDUAL PROVIDER OF PROFESSIONAL SUPERVISED VISITATION SERVICES I, _____________________________________, declare as follows: 1. I have read and understand Family Code §3200.5 and California Rules of Court Standard of Judicial Administration 5.20. 2. I certify that I meet all of the qualifications and training requirements for professional providers of supervised visitation services as stated in Family Code §3200.5 and Standard 5.20. 3. I certify that in providing services as a supervised visitation monitor, I will comply with all of the standards, procedures, responsibilities, requirements, and other provisions of Family Code §3200.5 and Standard 5.20. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: ____________________ ____________________________________ Signature Mandatory Form VN221 (Rev. 07/13) DECLARATION OF INDIVIDUAL PROVIDER OF PROFESSIONAL SUPERVISED VISITATION SERVICES Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com