STATE OF NORTH CAROLINA File No. __________________ COUNTY OF __________________ IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION In the Matter of the Custody of (Full name of child). ORDER (Present address of child) (Uniform Child Custody Jurisdiction Act) (Full name of person having present custody) (Address) (If different from child) This matter coming on to be heard upon the petition of ___________________________________ , who is a parent person acting as a parent to the minor child whose custody is being sought, a copy of which has been served as provided by N.C.G.S., 1A-1, Rule 4, upon the person having present physical custody of the child, upon each of the parents whose parental rights have not been terminated, and upon each of the parties contending a right to custody, if any, as follows: on by date on by date on by date and it appearing to the Court, and the Court finding from the testimony and other evidence presented the following: FACTS I. That this Court has jurisdiction to make a child custody determination by initial or modification decree for the following reasons: (Words stricken out and statements left unchecked will be deemed inapplicable.) a. This State is the home State of the child at the time of commencement of this action; that the petitioner ___________________________ and _____________________________- are the parents of the child, that the petitioner has the actual care and custody of the child; that petitioner is a citizen of the State of ________________________ and the other parent ___________________________ is a citizen of the State of _______________________ . b. This State has been the childs home State within six (6) months before commencement of this action, and the child has been removed or retained by a person claiming custody in another State, and a parent or person acting as parent continues to live in this State. c. It is in the best interests of the child that a Court of this State assume jurisdiction because the child and the childs parents, or the child and at least one contestant have a significant connection with this State, and there is available in this State substantial evidence relevant to the childs present or future care, protection, training and personal relationship. District 1 Page 1 of 3 FDCVD-6 Order (Uniform Child Custody Jurisdiction Act) >>>> 2 d. The child is in this State, and has been abandoned, or it is necessary in an emergency to protect the child because the child has been subjected to or threatened with mistreatment or abuse or is otherwise neglected or dependent. e. It appears that no other State would have jurisdiction under prerequisites substantially in accordance with a., b., c, or d. above, or another State has declined to exercise jurisdiction on the ground that this State is the more appropriate forum to determine the custody of the child, and it is in the best interests of the child that this Court assume jurisdiction. II. That from the pleadings and other information supplied by the parties, and from investigation of the child custody registry with respect to pendency of proceedings in other states, the Court has determined: a. That there is no proceeding for custody of this child pending in another State, or county of this State. b. That a proceeding for custody of this child is pending in the Court of ________________ ______________ , and such proceeding has has not been stayed pending the proceeding before this Court. III. That this Court has has not communicated with the _______________________________ Court of ___________________________________________ , or with the Court Administrator of the State of _____________________________________ , to exchange information as to the more appropriate forum to determine the custody of the minor child. IV. That the petitioner has wrongfully taken the child from another State, or has engaged in similar reprehensible conduct. V. That the petitioner has improperly removed the child from the custody of another, or has violated the provisions of a custody decree of another State. Upon the foregoing findings of fact, the Court makes the following CONCLUSIONS Conclusions not checked will be deemed inapplicable. A. That this Court has the right, under the provisions of North Carolina General Statutes Chapter 50A, to exercise jurisdiction in the determination of the custody of the minor child, and that it is the most appropriate forum, and that this Court should assume jurisdiction to make such determination. B. That this Court declines to exercise its jurisdiction for the reason that it is an inconvenient forum, based upon: (Reasons not checked will be deemed inapplicable.) 1. The fact that the child is, or recently was, a resident of the county of _________________ , State of ______________________________ . 2. The fact that the county of _____________________ , State of _____________________ , has a closer connection with the child and one or more of the contestants. 3. The fact that substantial evidence relevant to the childs present or future care, protection, training and personal relationships is more readily available in the county of ____________________________ , State of ___________________________ . District 1 Page 2 of 3 FDCVD-6 Order (Uniform Child Custody Jurisdiction Act) >>>> 3 4. The fact that the parties have agreed upon another forum which is not less appropriate, viz: ________________________________________________________________________ . 5. The fact that the exercise of this Courts jurisdiction would contravene any of the purposes stated in N.C.G.S. 50A-1. 6. The fact that custody determination in this matter is incidental to an action for divorce or other proceedings. 7. The fact that the petitioner has wrongfully taken the child from another State or engaged in other reprehensible conduct, or has violated the provisions of a custody decree of another State. Upon the foregoing Findings of Fact and Conclusions of Law it is, therefore, ORDERED, ADJUDGED AND DECREED 1. .That this Court is the more appropriate forum for determination of the custody of the minor child (children) and does assume jurisdiction therefore, and that this matter shall be calendared for hearing on _______________________________ , 2_______ , at ______________ ; oclock AM PM, or as soon thereafter as it may be heard before this Court. 2. That the Court of the County of ________________________________ be, and