IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI FAMILY COURT DIVISION  AT KANSAS CITY AT INDEPENDENCE ________________________________________________ PETITIONER NAME ____________________________________________________________ NO.__________________________________________________ ____________________________________________________________ STREET ADDRESS __________________________________________________ DATE, TIME AND DIVISION OF HEARING ____________________________________________________________ CITY STATE ZIP ___________________________________________________ RECEIPT NUMBER ____________________________________________________________ RESIDENCE PHONE WORK PHONE  Personal Service Requested  Private Process Server VS. _____________________________________________________________ RESPONDENT NAME _____________________________________________________________ _____________________________________________________________ STREET ADDRESS _____________________________________________________________ CITY STATE ZIP _____________________________________________________________ RESIDENCE PHONE WORK PHONE FAMILY ACCESS MOTION  An order establishing custody and visitation has been entered in Jackson County, Missouri. (Petitioner) (Respondent)_________________________________________, hereby states that custody and/or visitation as ordered by (Your Name) the Court has been denied or interfered with by a parent or third party without good cause. Please provide the specific facts including dates and times which constitute a violation of the above-referenced Court order: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Pursuant to Section 452.400, RSMo, I request that the Court find that (respondent) (petitioner): (check boxes that apply)    Violated the order for custody. Violated the order for visitation. Violated the order for third party custody. I request that the (respondent) (petitioner) be ordered to:  Provide a compensatory period of custody visitation or third-party custody at a time convenient for the aggrieved party not less than the period of time denied;  Participate in counseling to educate the violator about the importance of providing the child with a continuing and meaningful relationship with both parents;     Pay a fine up to five hundred dollars ($500.00);  Post bond or security to ensure future compliance with the court’s order; Pay the cost of counseling to re-establish the parent-child relationship between the aggrieved party and the child; and Pay the reasonable expenses, including attorney’s fees and court costs actually incurred by the aggrieved party as a result of the denial of custody, visitation or third party custody. Other relief___________________________________________________________________________________________ ____________________________________________________________________________________________________. The court may schedule alternative dispute resolution. NOTICE PURSUANT TO SECTION 452.400, RSMO, YOU ARE REQUIRED TO RESPOND TO THE CIRCUIT COURT ADMINISTRATOR’S OFFICE, FAMILY COURT DIVISION WITHIN TEN DAYS OF THE DATE OF SERVICE. FAILURE TO RESPOND TO THE CIRCUIT COURT ADMINISTRATOR’S OFFICE MAY RESULT IN THE FOLLOWING: (1) AN ORDER FOR A COMPENSATORY PERIOD OF CUSTODY VISITATION OR THIRD-PARTY CUSTODY AT A TIME CONVENIENT FOR THE AGGRIEVED PARTY NOT LESS THAN THE PERIOD OF TIME DENIED: (2) PARTICIPATION BY THE VIOLATOR IN COUNSELING TO EDUCATE THE VIOLATOR IN COUNSELING TO EDUCATE THE VIOLATOR ABOUT THE IMPORTANCE OF PROVIDING THE CHILD WITH A CONTINUING AND MEANINGFUL RELATIONSHIP WITH BOTH PARENTS: (3) ASSESSMENT OF A FINE UP TO FIVE HUNDRED DOLLARS ($500.00) AGAINST THE VIOLATOR: (4) REQUIRING THE VIOLATOR TO POST BOND OR SECURITY TO ENSURE FUTURE COMPLIANCE WITH THE COURT’S ORDER: (5) ORDERING THE VIOLATOR TO PAY THE COST OF COUNSELING TO RE-ESTABLISH THE PARENT-CHILD RELATIONSHIP BETWEEN THE AGGRIEVED PARTY AND THE CHILD; AND (6) A JUDGMENT IN AN AMOUNT NOT LESS THAN THE REASONABLE EXPENSES, INCLUDING ATTORNEY’S FEES AND COURT COSTS ACTUALLY INCURRED BY THE AGGRIEVED PARTY AS A RESULT OF THE DENIAL OF CUSTODY, VISITATION OR THIRD PARTY CUSTODY. Petitioner/Respondent under oath says the facts stated in the above petition are true according to his/her best knowledge and belief. Any false statement of a material fact may serve as the basis for prosecution and conviction for perjury or denial of your petition. ____________________________ DATE __________________________________________________ PETITIONER’S/RESPONDENT’S SIGNATURE Subscribed and sworn to before me on_____________________________________________ KEEP A COPY OF THIS MOTION AND BRING IT TO COURT __________________________________________________ Deputy Clerk ORIGINAL (FILE IN COURT’S CASE FILE) CIRCT 08/06 American LegalNet, Inc. www.FormsWorkflow.com