SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION , Petitioner, v. Case Number , Respondent. Civil Action CONSENT TO MODIFICATION OF CUSTODY 1. I am the __ mother __ father __ legal guardian __ legal custodian of following minor child(ren), who are the subject of this Modification of Custody action filed by the Petitioner: Name of Child Male / Female Year of Birth 2. I hereby give my consent to the following provisions, by writing my initials next to them. I do not agree to any of the provisions unless I have written my initials next to them. [Write your initials next to only the ones to which you agree. Draw a line through the ones to which you do not agree] _____ (a) The Petitioner and I have reached an agreement on custody and visitation for the child(ren). The completed Permanent Parenting Plan is attached. I understand that it will be included in the final order in this case. On the issue of child support: [Write your initials next to only one of the following, (1) to (4).] _____(b) _____ (1) Child support has already been decided for the child(ren) by a Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Consent to Modification -- Rev. Sept. 2015 Provided by the Family Law Information Center court or agency in another case. _____ (2) I want the Court to decide child support and enter a child support order as part of this Modification of Custody case. (3) The Petitioner and I have reached an agreement on child support for the child(ren), and it is consistent with the Georgia child support guidelines. The completed Child Support Addendum is attached. I understand that it will be included in the final order in this case. 3. I have read this consent document, and I understand it. I am giving my consent freely. I have written my initials next to all of the provisions in Paragraph 2 to which I am agreeing. I am not being forced to sign this consent, and I believe the provisions initialed above are in the best interest of my child(ren). _____ Respondent (Signature) Name: _________________________________ Email: _____________________________ IF YOU DO NOT HAVE AN EMAIL ADDRESS, FILL OUT A CERTIFICATE OF NO EMAIL ADDRESS Telephone No.:_______________________ Subscribed & sworn to before me on , 20 . _______________________________ Notary Public Commission Expires: _____________ Consent to Modification -- Rev. Sept. 2015 Provided by the Family Law Information Center Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com