STATE OF HAWAI221I FAMILY COURT THIRD CIRCUIT NOTICE OF INTENT TO FILE A COMPLAINT AGAINST A PRIVATE CHILD CUSTODY EVALUATOR CASE NUMBER FC255No. I, Name of Party/Complainant am the ~ Plaintiff/Petitioner ~Defendant/Respondent in FC255No. : . Case Name (Plaintiff/Petitioner vs. Defendant/Respondent) I am informing the Family Court of my intent to file a complaint against: who is a licensed Name of Private Child Custody Evaluator ~ Physician who has completed a residency in psychiatry ~ Board Certified Psychiatrist ~ Psychologist~ Marriage and Family Therapist ~ Clinical Social Worker and was appointed to perform a child custody evaluation and report in the above-entitled case. The following is a summary of my complaint: I declare under penalty of perjury under the laws of the State of Hawai221i that the foregoing is true and correct. Date Signature of Party/Complainant In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require areasonable 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 NOTICE OF INTENT TO FILE A COMPLAINT AGAINST A PRIVATE CHILD CUSTODY EVALUATOR 002003 002003 American LegalNet, Inc. www.FormsWorkFlow.com