Free JV-295.v3.092606.mc.ofm - California

Clerk stamps below when form is filed.

JV-295

De Facto Parent Request

The address of any licensed foster family home must remain confidential unless the judge or the foster parent authorizes release of the address. Court clerks should not send this page to the parties without a court order or authorization of the foster parent. (Welf. & Inst. Code, § 308(a).)
Court name and street address:

1

My/Our name(s):

Superior Court of California, County of

My/Our address: City: My/Our phone #: ( 2 ) State: Zip:
Case Number:

I am/We are asking that I/we be appointed de facto parent(s) of (Child's name):

Date:
Type or print your name Signature of person requesting de facto parent status

Date:
Type or print your name Signature of person requesting de facto parent status

Date:
Type or print attorney's name Signature of attorney (if applicable)

Attorney's address: City: Attorney's phone #: ( ) State: Zip:

Judicial Council of California, www.courtinfo.ca.gov Revised January 1, 2007, Mandatory Form Cal. Rules of Court, rule 5.534(e)

De Facto Parent Request

JV-295, Page 1 of 1
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