Form 364 Rev 2/2019 1 of 3 The Family Court of the State of Delaware In and For New Castle County Kent County Sussex County CUSTODY, VISITATION, AND GUARDIANSHIP DISCLOSURE REPORT Name : File Number : Relationship to the child ( ren ) : Petition Number: Date of Birth: Home Phone Number: Address: Work Phone Number: Cell Phone Number: Names and dates of birth of any child(ren) involved in this proceeding: 1. DOB: 4. DOB: 2. DOB: 5. DOB: 3. DOB: 6. DOB: Names and dates of birth of all persons living in your household , and relationship to the child (ren) : 1. DOB: Relationship to Child( ren) : 2. DOB: Relationship to Child ren) : 3. DOB: Relationship to Child (ren) : 4. DOB: Relationship to Child (ren) : 5. DOB: Relationship to Child (ren) : 6. DOB: Relationship to Child (ren) : 1. What contact schedule do you have now with the child ( ren ) noting how often the child ( ren ) live (s) with you or visit (s) with you? 2. This schedule is by: court order or by agreement 3. What contact schedule are you requesting for yourself with the child(ren)? Primary residency, with visitation with the other party OR Shared Placement Visitation, with primary residency with the other party If you want primary residency, what visitation schedule do you want the visiting party to have with the child(ren)? If you want shared residency, how would you like to share the time with the other party? American LegalNet, Inc. www.FormsWorkFlow.com 2 of 3 4. Legal custody refers to a parent222s right to make decisions regarding the child, not where the child primarily lives. Joint legal custody means that the parents share the duties and responsibilities of raising the child and are expected to share information and decide major issues about the child together. Sole legal custody means that one parent has decision - making authority although both parents have access to the child and the right to request information about the child. Requesting Joint Legal Custody Requesting Sole Legal Custody If you are requesting sole legal custody, explain why . 5. Where do you work and what is your work schedule? 6. How many miles do you live from the other party ? 7. How many miles do you live from the child(ren)222s school? 8. In w hich school district do you live? 9. How many miles does the other party live from the child(ren)222s school? 10. In what school district does the other party live? 1 1 . Do you have any history of drug or alcohol abuse? Yes No If yes, describe: 1 2 . Does the other party have any history of drug or alcohol abuse? Yes No If yes, describe: 1 3 . Do you have any concerns about your physical or mental health? Yes No If yes, describe concerns: 1 4 . Do you have any concerns about the physical or mental health of the child ( ren ) ? Yes No If yes, describe concerns: 1 5 . Do you have any concerns about the physical or mental health of the other party? Yes No If yes, describe concerns: 1 6 . List all of your criminal convictions, including DUIs. The Court is required to check criminal histories of all parties and members of the household: 1 7 . List all criminal convictions of the other party of which you are aware, including DUIs: 1 8 . Do you intend to offer evidence of domestic violence at trial? American LegalNet, Inc. www.FormsWorkFlow.com 3 of 3 1 9 . Have you or the other party ever been investigated by the Division of Family Services or a child welfare agency in another state? Yes No If yes, explain: 20 . Do you or the other party have a finding of child abuse or neglect by the Division of Family Services or a child welfare agency in another state? Yes No If yes, explain: 2 1 . Has the child(ren) ever lived with anyone other than you or the other party? Yes No If yes, with whom did the child(ren) live and what were the dates: Any other information that you believe is relevant to this proceeding : There is a duty to supplement and/or update this report. As such, parties are free to amend without leave of the Court. Date Print Name Signature Attorney Print Name Attorney Signature Sworn to and subscribed before me this day of , Notary / Clerk of Court Date Affidavit of Exchange This Disclosure Report must be exchanged with the other party. Please check one of the following boxes indicating how this exchange occurred. I affirm that this Custody, Visitation, and Guardianship Disclosure Report was filed with my petition and was therefore served by the Court upon the other party. I affirm that this Custody, Visitation, and Guardianship Disclosure Report was filed with the Court after the filing of the petition. I further affirm that a true and correct copy of this Disclosure Report was placed in the U.S. mail on the day of , and sent to the other party or attorney at the address listed on the petition, first class postage pre-paid. I affirm that this Custody, Visitation, and Guardianship Disclosure Report was brought to the Family Court mediation conference on the day of , with a true and correct copy given to the other party. Date Print Name Signature Attorney Print Name Attorney Signature Sworn to and subscribed before me this day of , Notary / Clerk of Court Date American LegalNet, Inc. www.FormsWorkFlow.com