Superior Court of Washington County of In re the Custody of: No. Child(ren), Petitioner(s), and Nonparental Custody Petition (PTCUS) Respondent(s). I. Basis 1.1 Identification of Petitioner(s) Name (first/last) Birth date . Last known residence (county and state only) Relationship to children ________________________________________________________________. Name (first/last) Last known residence (county and state only) Birth date . Relationship to children ________________________________________________________________. 1.2 Identification of Respondent(s) Nonparental Custody Pet (PTCUS) - Page 1 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com (List each parent, any alleged biological parent, guardian, custodian, and any other person with court ordered time with the children. Do not list any parent whose rights have been terminated by court order.) Name (first/last) Birth date . Last known residence (county and state only) Relationship to children ________________________________________________________________. Name (first/last) Birth date . Last known residence (county and state only) Relationship to children ________________________________________________________________. Name (first/last) Birth date . Last known residence (county and state only) Relationship to children ________________________________________________________________. 1.3 Children for Whom Custody is Sought Name (first/last) Age Name (first/last) Age Name (first/last) Age Name (first/last) Age Name (first/last) Age Name (first/last) Age 1.4 Identification of all Adults Living in Petitioner(s)’ Household Name (first/last) Age Name (first/last) Age Name (first/last) Age Nonparental Custody Pet (PTCUS) - Page 2 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com 1.5 Indian Child Welfare Act Indian Child Status: [] One or more of the above-named children is or may be an Indian child as defined by the Indian Child Welfare Act, 25 USC § 1903, and notice of this action must be given in accordance with 25 U.S.C. § 1912 (a). [] None of the children are Indian children as defined by 25 U.S.C. § 1903. Jurisdiction: [] [] 1.6 The children are Indian children as defined by the Indian Child Welfare Act, 25 USC § 1903 but are not domiciled or residing within the boundaries of an Indian reservation; and no Tribal Court has continuing jurisdiction over the children; this court has jurisdiction under 25 USC §1911. The children are Indian children as defined by the Indian Child Welfare Act, 25 USC § 1903, and are domiciled or residing within the boundaries of an Indian reservation; or a Tribal Court has continuing jurisdiction over the children. Jurisdiction (Check all that apply.) [] The following respondents reside in the state of Washington (list the respondents): _______________________________________________________________________ _______________________________________________________________________. [] The following respondents were personally served with summons and petition within this state (list the respondents): _______________________________________________________________________ _______________________________________________________________________. [] The following respondents submitted to the jurisdiction of this state by consent as evidenced by joinder or consent to jurisdiction signed by respondent (list the respondents): _______________________________________________________________________ _______________________________________________________________________. [] The following respondents engaged in sexual intercourse in the state of Washington as a result of which the child may have been conceived (list the respondents): _______________________________________________________________________ _______________________________________________________________________. [] The following respondents resided with the child in this state (list the respondents): _______________________________________________________________________ _______________________________________________________________________. [] The following respondents resided in this state and provided prenatal expenses or support for the child (list the respondents): Nonparental Custody Pet (PTCUS) - Page 3 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com _______________________________________________________________________ _______________________________________________________________________. [] [] 1.7 The child resides in this state as a result of the acts or directives of the following respondents (list the respondents): _______________________________________________________________________ _______________________________________________________________________. Other: Jurisdiction Over the Child This court has jurisdiction over this proceeding for the reasons below. [] This court has exclusive continuing jurisdiction. The court has previously made a child custody, parenting plan, residential schedule or visitation determination in this matter and retains jurisdiction under RCW 26.27.211. [] This state is the home state of the children because: [] [] [] [] [] the children lived in Washington with a parent or a person acting as a parent for at least six consecutive months immediately preceding the commencement of this proceeding. the children are less than six months old and have lived in Washington with a parent or a person acting as parent since birth. any absences from Washington have been only temporary. Washington was the home state of the children within six months before the commencement of this proceeding and the children are absent from the state but a parent or person acting as a parent continues to live in this state. The children and the parents or the children and at least one parent or a person acting as a parent have significant connection with the state other than mere physical presence, and substantial evidence is available in this state concerning the children's care, protection, training and personal relationships, and [] [] The children have no home state elsewhere. The children’s home state has declined to exercise jurisdiction on the ground that this state is the more appropriate forum under RCW 26.27.261 or .271. [] All courts in the children's home state have declined to exercise jurisdiction on the ground that a court of this state is the more appropriate forum to determine the custody of the children under RCW 26.27.261 or .271. [] No other state has jurisdiction. [] This court has temporary emergency jurisdiction over this proceeding because the children are present in this state and the children have been abandoned or it is necessary in an Nonparental Custody Pet (PTCUS) - Page 4 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com emergency to protect the children because the children, or a sibling or parent of the children is subjected to or threatened with abuse. RCW 26.27.231. [] [] [] 1.8 There is a previous custody determination that is entitled to be enforced under this chapter or a child custody proceeding has been commenced in a court of a state having jurisdiction under RCW 26.27.201 through 26.27.221. The requirements of RCW 26.27.231(3) apply to this matter. This state’s jurisdiction over the children shall last until (date) _______________________________. There is no previous custody determination that is entitled to be enforced under this chapter and a child custody proceeding has not been commenced in a court of a state having jurisdiction under RCW 26.27.201 through 26.27.221. If an action is not filed in (potential home state) _____________________ by the time the child has been in Washington for six months, (date) ___________________, then Washington's jurisdiction will be final and continuing. Other: Uniform Child Custody Jurisdiction and Enforcement Act Information Name of Child Parent's Name Parent’s Name The children permanently reside(s) in this county or can be found in this county. During the last five years, the children have lived: [] [] in no place other than the state of Washington and with no person other than the petitioner or the respondent. in the following places with the following persons (list each place the children lived, including the state of Washington, the dates the children lived there and the names of the persons with whom the children lived. The present addresses of those persons must be listed in the required Confidential Information Form): Claims to custody or visitation: Nonparental Custody Pet (PTCUS) - Page 5 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com [] [] The petitioner does not know of any person other than the respondent who has physical custody of, or claims to have custody or visitation rights to, the children. The following persons have physical custody of, or claim to have custody or visitation rights to, the children (list their names and the children concerned below and list their present addresses in the Confidential Information Form. Do not list the responding party): Involvement in any other proceeding concerning the children: [] [] The petitioner has not been involved in any other proceeding regarding the children. The petitioner has been involved in the following proceedings regarding the children (list the court, the case number, and the date of the judgment or order): Other legal proceedings concerning the children: [] [] 1.9 The petitioner does not know of any other legal proceedings concerning the children. The petitioner knows of the following legal proceedings that concern the children (list the children concerned, the court, the case number and the kind of proceeding): Visitation Respondent (name) _________________________________: Visitation should be [ ] as set forth in the attached proposed Residential Schedule which is incorporated by reference as part of this Petition; or [ ] as follows: [] Parental visitation should be limited because (name) ___________________________ has engaged in the conduct which follows: [] [] [] Willful abandonment that continues for an extended period of time or substantial refusal to perform parenting functions. Physical, sexual or a pattern of emotional abuse of a child. A history of acts of domestic violence as defined in RCW 26.50.010(1) or an assault or sexual assault which causes grievous bodily harm or the fear of such harm. Nonparental Custody Pet (PTCUS) - Page 6 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com Respondent (name) _________________________________: Visitation should be [ ] as set forth in the attached proposed Residential Schedule which is incorporated by reference as part of this Petition; or [ ] as follows: [] Parental visitation should be limited because (name) _________________________ has engaged in the conduct which follows: [] [] [] [] 1.10 Willful abandonment that continues for an extended period of time or substantial refusal to perform parenting functions. Physical, sexual or a pattern of emotional abuse of a child. A history of acts of domestic violence as defined in RCW 26.50.010(1) or an assault or sexual assault which causes grievous bodily harm or the fear of such harm. Other: Child Support Support for the dependent children should be set pursuant to the Washington State child support statutes. 1.11 Health Insurance Coverage Either or both parents should be required to maintain or provide health insurance coverage consistent with RCW 26.10.060. 1.12 Continuing Restraining Order [] [] [] [] Does not apply. (Name) ______________________________ should be restrained or enjoined from disturbing the peace of the other party or of any child. (Name) ______________________________ should be restrained or enjoined from going onto the grounds of or entering the home, work place or school of the other party or the day care or school of the following named children: ______________________ _____________________________________________________________________. (Name) _______________________________ should be restrained or enjoined from knowingly coming within or knowingly remaining within (distance) ______________ of Nonparental Custody Pet (PTCUS) - Page 7 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com [] [] [] [] 1.13 Other: Adequate Cause [] [] 1.14 the home, work place or school of the other party or the day care of school of these children: _________________________________________________________________ A continuing restraining order should be entered which restrains or enjoins (name) _________________________ from molesting, assaulting, harassing, or stalking (name) _____________________________. (Name) ______________________________ should be restrained or enjoined from removing any of the children from the state of Washington. (Name) ______________________________ should be required to surrender any deadly weapon in his or her immediate possession or control or subject to his or her immediate possession or control to the sheriff of the county having jurisdiction of this proceeding, to his or her lawyer or to a person designated by the court. Clear and convincing reasons for this request are set forth in paragraph 1.12 below. (See RCW 26.09.060 (2)(b).) The children have not been in the physical custody of either parent since (date) ________________________________. Neither parent is a suitable custodian for the children because: Best Interest of the Children The requests made in this petition are in the best interests of the children because: Nonparental Custody Pet (PTCUS) - Page 8 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com 1.15 Other II. Relief Requested The petitioner requests that the court enter an order finding that there is adequate cause for hearing this petition and giving petitioner custody of the children listed in paragraph 1.3 of this petition and requiring either or both parents to maintain or provide health insurance coverage for the children consistent with RCW 26.10.060. The petitioner also requests the relief described below. [] [] [] [] [] [] [] [] Determine support for the dependent children pursuant to the Washington State Child Support Schedule. Approve my proposed Residential Schedule, or order visitation pursuant to paragraph 1.9. Award the tax exemptions for the dependent children as follows: Enter a continuing restraining order. Enter a [ ] domestic violence [ ] antiharassment protection order protecting (name) __________________________ from (name) __________________________ . If you check this box, contact the clerk/court for RCW 26.50 Domestic Violence forms or for RCW 10.14 Antiharassment forms. Order payment of day care expenses for the children. Order payment of attorney fees, other professional fees and costs. Other: Date Signature Petitioner or Lawyer/WSBA No. Print or Type Name Date Signature Petitioner or Lawyer/WSBA No. Print or Type Name I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) _________________________, (state) __________ on (date) ____________________. Nonparental Custody Pet (PTCUS) - Page 9 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com Signature of Petitioner Print or Type Name Signed at (city) _________________________, (state) __________ on (date) _____________________. Signature of Petitioner Print or Type Name [] Joinder [] I, _______________________, join in the petition. I understand that by joining in the petition, a decree or judgment and order may be entered in accordance with the relief requested in the petition unless, prior to the entry of the decree or judgment and order, a response is filed and served. [] [] I waive notice of entry of the decree. I demand notice of all further proceedings in this matter. Further notice should be sent to the following address: (you may list an address that is not your residential address where you agree to accept legal documents.) Any time this address changes while this action is pending, you must notify the opposing parties in writing and file an updated Confidential Information Form (WPF DRPSCU 09.0200) with the court clerk. Date [] Signature of Respondent Print or Type Name I, _______________________, join in the petition. I understand that by joining in the petition, a decree or judgment and order may be entered in accordance with the relief requested in the petition unless, prior to the entry of the decree or judgment and order, a response is filed and served. [] [] I waive notice of entry of the decree. I demand notice of all further proceedings in this matter. Further notice should be sent to the following address: (you may list an address that is not your residential address where you agree to accept legal documents.) Any time this address changes while this action is pending, you must notify the opposing parties in writing and file an updated Confidential Information Form (WPF DRPSCU 09.0200) with the court clerk. Date Signature of Respondent Print or Type Name Nonparental Custody Pet (PTCUS) - Page 10 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com [] I, _______________________, join in the petition. I understand that by joining in the petition, a decree or judgment and order may be entered in accordance with the relief requested in the petition unless, prior to the entry of the decree or judgment and order, a response is filed and served. [] [] I waive notice of entry of the decree. I demand notice of all further proceedings in this matter. Further notice should be sent to the following address: (you may list an address that is not your residential address where you agree to accept legal documents.) Any time this address changes while this action is pending, you must notify the opposing parties in writing and file an updated Confidential Information Form (WPF DRPSCU 09.0200) with the court clerk. Date Signature of Respondent Print or Type Name Nonparental Custody Pet (PTCUS) - Page 11 of 11 WPF CU 01.0100 Mandatory (6/2008) - RCW 26.10.030(1) American LegalNet, Inc. www.FormsWorkflow.com