FACTORS FOR CONSIDERATION IN CUSTODY AND VISITATION PURSUANT TO CHAPTER 50B 1. With whom have the children been living during the last six months? (Please check the appropriate answer) Mother _____ Father ______ Both parents______ Other ________________ 2. Who has been mainly responsible for taking care of the child or children during the last six months? (e.g. taking them to school, doctor's appointments; preparing meals; laundry; etc.) Describe roles of parents. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Were there acts of physical violence against the children? If so, describe below. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Were the children present when the acts alleged in the request for a restraining order occurred? Yes _____ No ______ Name the children ________________________________________________________ ________________________________________________________________________ Were the children present when other acts of physical violence or threats of physical violence occurred in the past or have they observed acts of physical violence that occurred in the past? If so, describe below. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Was the child harmed (physically, emotionally or placed in fear of injury) by any acts of physical violence or threats of physical violence in the past? If so, describe below. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Are there any other court cases involving the parties or minor children in this action? (e.g. criminal charges, other requests for restraining orders, abuse or neglect investigations/petitions, juvenile actions, child support, custody/visitation, spousal support, or property distribution) If so, list below. 3. 4. 5. 6. 7. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ WAKE-DOM-28 (2/06) (PAGE 1 of 2) American LegalNet, Inc. www.USCourtForms.com 8. 9. Has social services been involved with your family? Yes______ No ______ Do you want the judge to: Order the children to live with you? Yes_____ No_____ Allow the children to live the other parent, but visit with you? Yes__ No___ 10. If the judge orders the children to live with the other parent, do you want the judge to establish a regular visitation schedule for you? Yes____ No _____ If you answered yes, please indicate when you are available to see them each week? Every weekend from Friday to Sunday____ Saturday from ____ to ____ Sunday from ___ to ____ Other ­ Describe: _________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 11. If the judge orders the children to live with you, do you think the other parent's visits with the children should be supervised? If you answered yes, please explain why and how below. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 12. When you exchange the children with the other parent, where do you want the exchange to occur? Your home________ The other parent's home The children's school/daycare_______ Local police department_____________ Supervised exchange center_____ Other (be specific)_________________________________________________ The above answers are true. __________________________________ NAME OF PARENT _______________ DATE WAKE-DOM-28 (2/06) (PAGE 2 of 2) American LegalNet, Inc. www.USCourtForms.com