Superior Court of Washington, County of In re custody of: Children: No. Petitioner/s (person/s who started this case): Final Non-Parent Custody Order (DCC) Clerk's action required: 1, 7, 9, 10 Respondents (parents and any guardian or custodian): Final Non-Parent Custody Order 1. Money Judgment Summary No money judgment is ordered. Summarize any money judgment from section 7 in the table below. Judgment for Debtor's name (person who must pay money) Creditor's name (person who must be paid) Amount Interest Lawyer fees Guardian ad litem (GAL) fees Court costs Other fees and expenses (specify): Yearly Interest Rate: ____% (12% unless otherwise listed) Lawyer (name): Lawyer (name): represents (name): represents (name): $ $ $ $ $ $ RCW 26.10.040, .170 Mandatory Form (05/2016) FL Non-Parent 431 Final Non-Parent Custody Order p. 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com  The court has made Findings and Conclusions in this case and now Orders: 2. Custody The Petitioners are granted custody of the following children: Child's Name 1. 3. 5. Age Child's Name 2. 4. 6. Age 3. Petitioner's Authority The Petitioner/s have the right to make decisions and determine the children's upbringing, including their education, health care, and religious training. There are no limits on the Petitioner's authority over the children's upbringing or decision-making for the children. Petitioner's authority is limited as follows: (Specify limitation): (Agency): shall exercise continuing supervision over the case to assure that the custodian is following the custodial or visitation terms of the order. The agency shall: Other: 4. Respondent's Visitation Respondent (name): shall have (check one): visitation as listed in the Residential Schedule signed by the court and filed separately today or on (date): . no visitation with the children. The following reasons for limiting visitation apply and are severe enough to justify no visitation (check all that apply): Abandonment ­ s/he intentionally abandoned a child listed in 2 for an extended time. Neglect ­ s/he substantially refused to perform his/her parenting duties for a child listed in 2. Child Abuse ­ s/he (or someone living in that parent's home) abused or threatened to abuse a child. The abuse was (check all that apply): physical sexual repeated emotional abuse. Domestic Violence ­ s/he (or someone living in that parent's home) has a history of domestic violence as defined in RCW 26.50.010(1). Assault ­ s/he (or someone living in that parent's home) has assaulted or sexually assaulted someone causing grievous physical harm or fear of such harm. RCW 26.10.040, .170 Mandatory Form (05/2016) FL Non-Parent 431 Final Non-Parent Custody Order p. 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Sex Offense ­ s/he has been convicted of a sex offense as an adult. someone living in his/her home has been convicted as an adult or adjudicated as a juvenile of a sex offense. Other Reason (specify): 5. Other Respondent's Visitation There is no other Respondent. Respondent (name): shall have (check one): . visitation as listed in the Residential Schedule signed by the court and filed separately today or on (date): no visitation with the children. The following reasons for limiting visitation apply and are severe enough to justify no visitation (check all that apply): Abandonment ­ s/he intentionally abandoned a child listed in 2 for an extended time. Neglect ­ s/he substantially refused to perform his/her parenting duties for a child listed in 2. Child Abuse ­ s/he (or someone living in that parent's home) abused or threatened to abuse a child. The abuse was (check all that apply): physical sexual repeated emotional abuse. Domestic Violence ­ s/he (or someone living in that parent's home) has a history of domestic violence as defined in RCW 26.50.010(1). Assault ­ s/he (or someone living in that parent's home) has assaulted or sexually assaulted someone causing grievous physical harm or fear of such harm. Sex Offense ­ s/he has been convicted of a sex offense as an adult. someone living in his/her home has been convicted as an adult or adjudicated as a juvenile of a sex offense. Other Reason (specify): 6. Support, insurance and taxes The court is not issuing an order about support, insurance or taxes at this time. Child Support ­ The court (check one): signed the final Child Support Order and Worksheets filed separately today or on (date): . is not issuing a child support order. There is an administrative child support order(s) established by DSHS Division of Child Support (DCS). RCW 26.10.040, .170 Mandatory Form (05/2016) FL Non-Parent 431 Final Non-Parent Custody Order p. 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com DCS child support orders do not cover tax exemptions or post-secondary (college or vocational school) support. Health Insurance or other expenses ­ The parents must pay for health insurance, uninsured medical, day care, or other necessary expenses (check one): as listed on the final Child Support Order. as follows (specify): Tax Exemptions ­ The parties have the right to claim the children as their dependents on their tax forms as follows (check one): as listed on the Child Support Order. Petitioners may claim the children. other (specify): Warning! Under federal law, the person who claims a child as a dependent may owe a tax penalty if the child is not covered by health insurance. Other (specify): 7. Money Judgment for fees and costs (summarized on page 1) No money judgment is ordered. The court orders a money judgment for fees and costs as follows: Judgment for Debtor's name (person who must pay money) Creditor's name (person who must be paid) Amount Interest Lawyer fees Guardian ad litem (GAL) fees Court costs Other fees and expenses (specify): The interest rate is 12% unless another amount is listed below. The interest rate is % because (explain): $ $ $ $ $ $ $ $ 8. Protection Order No one requested an Order for Protection in this case. Approved ­ The request for an Order for Protection is approved. The Order for Protection is filed separately. Denied ­ The request for an Order for Protection is denied. The Denial Order is filed separately. RCW 26.10.040, .170 Mandatory Form (05/2016) FL Non-Parent 431 Final Non-Parent Custody Order p. 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Renewed/Changed ­ The existing Order for Protection filed in or combined with this case is renewed or changed as described in the following order,