REQUEST FOR VIRGINIA REGISTRATION OF A CHILD CUSTODY AND/OR VISITATION DETERMINATION FROM ANOTHER STATE Case No. Commonwealth of Virginia Va. Code 20-146.26 Juvenile and Domestic Relations District Court CITY/COUNTY COURT ADDRESS In re: NAME OF CHILD WHO IS SUBJECT OF DETERMINATION TO BE REGISTERED DATE OF BIRTH OF CHILDName of Person Requesting Registration: Address of Person Requesting Registration: [ ] I allege under oath that the health, safety or liberty of a party or chi ld would be jeopardized by disclosure of identifying information. Therefore, I request that this do cument be sealed pursuant to the provisions of subsection E of Virginia Code 20-146.20 and the addre ss above not be disclosed. Name and Address of Persons other than the person requesting registratio n who have been awarded custody or visitation in the attached child custody and/or visitation determination : NON-REGISTERING PARTY OTHER INTERESTED PERSON ADDRESS ADDRESS I request that the clerk of the above-named court register the attached certified child custody and/or visitation determination. Two copies (including at least one certified copy) of the child custody and/or visitation determination are attached. I state, under penalty of perjury, that to the best of my knowledge and belief, the attached child custody and/or visitation determination has not been modified. DATE SIGNATURE OF REQUESTOR Subscribed and sworn to before me this day by DATE [ ] CLERK [ ] DEPUTY CLERK [ ] MAGISTRATE [ ] NOTARY PUBLIC: My Commission Expires: FORM DC-582 (PAGE ONE OF ONE) REVISED 9/02 PDF American LegalNet, Inc. www.USCourtForms.com