IN THE _____ JUDICIAL CIRCUIT COURT, ____________________________, MISSOURI Affidavit of Changes in Circumstance and Motion to Modify Judgment/Full Order of Child Protection Use this form when one child is involved with this case. Use CP56 for two to five children and CP53 for six to ten children. Judge or Division: Petitioner: Case Number: Court ORI Number: MSHP Number: Responsible Law Enforcement ORI: Related Cases: (Date File Stamp) Protected Child's Relationship to Respondent pursuant to 18 U.S.C. §§ 921(a)(32) and 922(g)(8) determination: Protected Child's Relationship to Respondent: Child Step-Child or Former Step-Child Parent is Unmarried, Intimate Residing/Resided with Respondent Other (specify) ____________________________________________ Respondent's Home Address: Protected Child: Age of Protected Child: Sex: F M Race: vs. Respondent: Alias/Nicknames: Respondent's DOB: SSN (if known, last four digits): Race: Sex: F M Home Phone Number: Respondent's Work Address: Work Phone Number: Work Hours: A Judgment/Full Order of Child Protection was entered in __________________________________ (County/City of St. Louis), Missouri, on ____________________________ (date). A change has occurred in the circumstances of the child(ren) or his/her custodian and the modification is necessary to serve the best interests of the child(ren). Below are the specific facts, including dates and times, which petitioner respondent Guardian ad Litem Court Appointed Special Advocate believes forms grounds for modification of the court's judgment: I request that the court find grounds for modification of: (check the box that applies) Installments of maintenance or support. Custody. Visitation. Other (specify): The specific modification that I am requesting is: Conditions regarding communication. Conditions regarding contact. OSCA (07-13) CP50 1 of 2 455.528, 455.530 RSMo American LegalNet, Inc. www.FormsWorkFlow.com I swear /affirm under penalty of perjury that these facts are true according to my best knowledge and belief. _________________________________________ Date _________________________________________________ Your Signature _________________________________________________ NOTICE: Section 455.510.3 RSMo provides that a Petitioner seeking protection under the Child Protection Orders Act is not required to reveal any current address or place of residence of the child(ren) on this petition. Do not provide this information if doing so will endanger the child(ren). In witness thereof: ___________________________________ Date Your Street Address _________________________________________________ City State Your Telephone Number Zip _________________________________________________ ______________________________________________ Clerk Witnessing Signature Subscribed and sworn to before me on this ________________________________ (date). (Seal) My commission expires: __________________ Date _______________________________ Notary Public Directions for Completing This affidavit must be completed and signature witnessed by a court clerk or notary before filing it with the court. OSCA (07-13) CP50 2 of 2 455.528, 455.530 RSMo American LegalNet, Inc. www.FormsWorkFlow.com