Circuit Court for Name Street Address City State Zip Code Area Code City or County Case No. vs. Apt. # Telephone Name Street Address City State Zip Code Area Code Apt. # Telephone Plaintiff Defendant COMPLAINT FOR VISITATION (CC-DR 5) I, 1. I am the , representing myself, state that: father or Relationship (for example, aunt, grandfather, guardian, etc.) My name mother of the following minor child(ren): Name of Child Name of Child Name of Child Date of Birth Date of Birth Date of Birth (Check one) Name of Child Name of Child Name of Child Date of Birth Date of Birth Date of Birth 2. The child(ren) live(s) at with Name and Relationship to child(ren) Address . 3. I know of the following cases concerning the child(ren) (such as domestic violence (protective order), paternity, divorce of the child(ren)'s parents, custody, visitation, termination of parental rights, adoption or other cases): Court Case No. Kind of Case Year Filed Results or Status (if you know) Attach the most recent court order for the above-referenced court cases. 4. I have been a party, witness, or otherwise involved in the following cases about custody or visitation of the child(ren): State Court Case No. Date of Child Custody Determination Attach the most recent court order for the above-referenced court cases. CC-DR 5 (Rev. 10/2015) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. I know of the following people, not parties to this case, who have physical custody of, or claim rights of legal custody or physical custody of, or visitation with the child(ren): Name Name Name Current Address Current Address Current Address 6. It is in the best interests of the child(ren) to visit with me because: FOR THESE REASONS, I request the court grant me reasonable visitation as follows: and any other appropriate relief. I, solemnly affirm under the penalties of Your Name perjury, that the contents of this document are true to the best of my knowledge, information and belief. Date Signature CC-DR 5 (Rev. 10/2015) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com