VN222 Superior Court of California County of Ventura DECLARATION OF ORGANIZATION PROVIDING PROFESSIONAL SUPERVISED VISITATION SERVICES I, ________________________________________________, declare as follows: 1. I am __________________________________________ of the following (title or role in organization) agency, center, partnership, corporation or other entity or organization, and I am authorized to sign this declaration on its' behalf: Name of organization: ____________________________________________________ Address of organization: _________________________________________ _________________________________________ Primary contact in organization: ____________________________________________ ______________________ Phone ____________________________________________ E-mail 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 each person, whether an employee, intern, volunteer, or independent contractor, who provides supervised visitation services on behalf of or by referral through the above named organization, will meet all of the qualifications and training requirements for professional supervised visitation monitors as stated in Family Code §3200.5 and Standard 5.20. 3. I certify that each person, whether an employee, intern, volunteer, or independent contractor, who provides supervised visitation services on behalf of or by referral through the above named organization, 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 VN222 (Rev. 07/13) DECLARATION OF ORGANIZATION PROVIDING PROFESSIONAL SUPERVISED VISITATION SERVICES Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com