STATE OF HAWAI‘I FAMILY COURT __________ CIRCUIT CASE NUMBER CUSTODY/VISITATION STATEMENT FC-D NO. 1. The parties are the parents of: born born born _______________________________________________ born ________________________________________ 2. The child/ren whose custody/visitation is at issue (“the subject child/ren”) is/are: 3. The current address(es) of the subject child/ren is/are: ______________________________________ 4. The address(es) where the subject child/ren has/have lived in the past five (5) years are: _____________________________________________________________________________________________ 5. The name(s) and current address(es) of the person(s) with whom the subject child/ren has/have lived within the last five (5) years is/are: _____________________________________________________________________________________________ 6. [ ] [ ] 7. [ ] [ ] 8. [ ] [ ] I have not participated in the past as a party, witness, or in any other capacity in any litigation in Hawai‘i or elsewhere involving the subject child/ren. Other litigation involving the subject child/ren (including both those in which I have participated as a party, witness, or in any other capacity, as well as those in which I have not participated) has been as follows: Case name ____________________________________________________________________________ Case number __________________________________________________________________________ Location of Court ______________________________________________________________________ Date filed ___________________ Date concluded ____________________ Type of case ___________________________________________________________________________ I do not know of any custody proceeding currently pending in Hawai‘i or elsewhere involving the subject child/ren. The following proceedings involving the subject child/ren are currently pending in Hawai‘i/elsewhere: Case name ____________________________________________________________________________ Case number __________________________________________________________________________ Location of Court ______________________________________________________________________ Date filed ___________________ Type of case ___________________________________________________________________________ I do not know of any person not a party to this case who is not identified in paragraph 5. above and who (a) has had the physical custody of the subject child/ren in the past and/or (b) claims to have custody/visitation rights with respect to the subject child/ren. The following other person(s) has/have had the physical custody of the subject child/ren and/or is/are claiming custody/visitation rights: ______________________________________ ________________________________________________________________________________________ _________________________________ Movant’s signature Revised 12/16/96 ________________ Date Custody/Visitation Statement American LegalNet, Inc. www.FormsWorkflow.com