STATE OF HAWAI221I FAMILY COURT THIRD CIRCUIT DECLARATION OF PRIVATE CHILD CUSTODY EVALUATOR REGARDING QUALIFICATIONS, CONTACT INFORMATION, AND FEES 1. Name: Address: Telephone Number: 2. I am licensed in the state of Hawai221i as a: ~ board certified psychiatrist under Hawai221i Revised Statutes (HRS) chapter 453. ~ physician under HRS chapter 453 who has completed residency in psychiatry. ~ psychologist under HRS chapter 465. ~ marriage and family therapist under HRS chapter 451J. ~ clinical social worker under HRS section 467E-7(3). My Hawai221i license number is: . My Hawai221i license expires on: . 3. I speak the following language(s): . 4. My fees are $ per hour. 5. I understand I can be removed from the Registry of Private Child Custody Evaluators at any time upon written notice from the Senior Family Court Judge for any reason including, but not limited to: a. failure to maintain my license; b. failure to inform the Senior Family Court Judge of (1) the revocation or suspension of my license within three days of such action being taken against me and/or (2) any changes to the information contained in my Declaration of Private Child Custody Evaluator Regarding Qualifications, Contact Information, and Fees form. I declare under penalty of perjury under the laws of the State of Hawai221i that the foregoing is true and correct. Date Signature of Declarant/Private Child Custody Evaluator Print Name: In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at PHONE NO. 961-7424, FAX 961-7411,or TTY 961-7422 at least ten (10) working days prior to your hearing or appointment date. FC Adm 7/1/13 DECLARATION OF PRIVATE CHILD CUSTODY EVALUATOR REGARDINGQUALIFICATIONS, CONTACT INFORMATION, AND FEES American LegalNet, Inc. www.FormsWorkFlow.com