(Clerks Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In re the Custody of: CASE NO. _____________________ Child(ren), DECLARATION OF PETITIONER(S) Petitioner(s), FOR NONPARENTAL CUSTODY and CLERKS ACTION REQUIRED Respondent(s). FILE IN CONFIDENTIAL FOLDER Petitioner must complete all the information below. I DECLARE: 1. Full name(s) of any person who lives with me or who spends time in my home, relationship to me, and length of time I have known them: 2. I do have / do not have any criminal history (including arrests) or Child Protective Service (CPS) history in this or any other state. Summary: DECLARATION OF PETITIONER(S) FOR NON-PARENTAL CUSTODY Page 1 of 3 (revised 8/03) >>>> 2 3. The following person(s) who lives with me or spends time in my home do have / do not have a criminal history (including arrests) or CPS history in this or any other state. Summary: 4. I have / have not been the subject of an Order of Protection or other civil restraining order that has restricted contact with another individual. The following person(s) who lives with me or who spends time in my home, have / have not been the subject of an Order of Protection or other civil restraining order which has restricted contact with another individual. Summary: 5. I have / have not been a party to a parenting plan that places restrictions on my residential time with children. The following person(s) who lives with me or who spends time in my home, have / have not been a party to a parenting plan which places restrictions on their residential time with children. Summary: 6. I have / have not been in treatment for substance abuse. I have / have not tested positive for alcohol and/or illegal substance. The following person(s) who live with me or spend time in my home, have / have not been in treatment for substance abuse, have or have not tested positive for alcohol and/or illegal substance. Summary: DECLARATION OF PETITIONER(S) FOR NON-PARENTAL CUSTODY Page 2 of 3 (revised 8/03) >>>> 3 7. The court should be aware of the following information about me or any person(s) who lives with me or spends time in my home that may affect its decision regarding the placement of the child(ren) with me. I declare under penalty of perjury under the laws of the State of Washington that the statement above is true and correct. Signed at Spokane, Washington, on ___________________________. ________________________________ Signature ________________________________ Print or Type Name DECLARATION OF PETITIONER(S) FOR NON-PARENTAL CUSTODY Page 3 of 3 (revised 8/03)