IN THE FAMILY CO URT OF ________________ CO UN TY, W EST VIR GIN IA In Re: The Marria ge / Children of: Civil Action No. ____________ _________________________, and _________________________. Petitioner Respondent _________________________ _________________________ _________________________ _________________________ Address Address ________________ ________________ Daytime phone Daytime phone NOTICE of RELOCA TION NOT ICE TO : ______________________________________ From: ___________________________________________ Take NOTICE that I pl an to relocate from my current address. I plan for our children to relocate with me. Informa tion regar ding my relocation plans, my proposals for changing the custodial responsibility arrangements under our court ordered Parenting Plan, and other importa nt information is set forth below. If you object to my planned relocation, or to my proposals for changing the Parenti ng Plans custodial responsibility arran gements, you must immediately send a writte n request for a hearing to me, and to the Family Court at this address: Information Regarding Planned Relocation 1. Name of person giving notice: __________________________________________ ________ 2. Under a court ordered Parenting Plan, I have custodial responsibility for the children whose names and ages I have listed below. ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ 3. I plan to relocate. I will be moving on or after this date: _____________________________. SCA-FC-131 (12/01 ) Notice of Relocation Page 1 of 3>>>> 2 4. My new address and telephone number will be: ___________________________________ ________________________________________________________________________ _. 5. I expect this relocation to be: ___ Permanent; ___ Less than ninety days. 6. I am giving this Notice of Relocation to _________________________________ who, along with me, has custodial responsibility for the children whose names are listed in Item 2. This persons current address and phone number are: ____________________________________ _____________________________________________________________. 7. I am relocating for the following purpose(s). (You MUST explain the purpose(s) for your move.) ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ 8. Because of my relocation, I propose that the Parenting Plans, custodial responsibility arrangements be changed in the following ways. ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ 9. I believe the other parent with custodial responsibility under the Parenting Plan can reasonably accommodate the changes I have proposed in item 6 in the following ways. ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ Continue to the next page. You must sign this Notice, and you must sign Verification that follows before a Notary Public or other authorized official. SCA-FC-131 (12/01 ) Notice of Relocation Page 2 of 3>>>> 3 __________________________ ____________________ Signature Date VERIFIC ATION I, ____________________________, after making an oath or affirmation to tell the truth, say that the facts I have stated in this Notice are true of my personal knowledge; and if I have set forth matters upon information given to me by others, I believe that information to be true. ___________________________ ____________ Signature Date This Verification was sworn to or affirmed before me on the ____ day of __________________, 20____. _________________________ My commission expires:______________________ Notary Public CERTIFICATE of SERVICE State of West Virginia County of _______________________________ I, ____________________________, mailed a Notice of Relocation by first class United States Mail, postage paid, to __________________________________, at the address of _______________________________________________, on the ____ day of __________________, 20___. ___________________________ ____________ Signature Date SCA-FC-131 (12/01 ) Notice of Relocation Page 3 of 3