Free Exhibit Pertaining to Conciliation, Child Care, and Child Custody Proceedings - Hawaii

STATE OF HAWAI`I FAMILY COURT THIRD CIRCUIT

EXHIBIT PERTAINING TO CONCILIATION, CHILD CARE, AND CHILD CUSTODY PROCEEDINGS

CASE NUMBER FC-

D

NO.

PREPARER (NAME, ADDRESS AND PHONE NO.)

Plaintiff, vs.

Name: Address:

Defendant. I. MARRIAGE INFORMATION 1. Are you presently separated? If yes, date separated:

Phone No.:

YES

NO

2. Have you had contact with your spouse at any time since your separation? If so, how frequently? Reasons for contacts: 3. What is your present relationship? II. COUNSELING INFORMATION 1. Have you or your spouse received marriage counseling services? If so, name of person/agency providing the service: Give approximate dates and numbers of interview: Date(s): Number of Interviews: 2. Did your spouse participate in these sessions? 3. What do you feel is the basic problem in your marriage breakdown? 4. Do you wish counseling? III. INFORMATION ON CARE OF CHILDREN: LIVING ARRANGEMENTS: (include type of house, rent/own, number of rooms, number of occupants) Good Fair Poor

SUPERVISION: Give details of care of children if you are employed and/or after school care:

3C-P-072
FORM NO. 073936 REPROGRAPHICS (6/08) (Continue on back page)

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EXHIBIT PERTAINING TO CONCILIATION, CHILD CARE AND CHILD CUSTODY PROCEEDINGS

EXPENSES: YES CUSTODY: Do you feel custody will be an issue? If yes, give NAMES OF CHILDREN whose custody is disputed and why you feel that you, rather than the other party, should have custody of the children: NO

VISITATION:

What are your feelings about the children's visits with other parent?

What are your plans for visitation IF YOU DO NOT have custody?

What other activity of yours makes you feel your having custody would be in the children's best interest?

What activity of your spouse makes you feel it would be in the children's best interest for your spouse to have custody?

IV. AGENCY INFORMATION: If you or a member of your family are now active or have been known to any of the following agencies, please indicate the year of last contact with the agency:
1. Dept. of Social Services & Housing _________________ 2. Adult Probation ______________________ 3. Family Court ___________________________________ 4. Mental Health Clinic __________________ 5. Other (Name) _________________________________________________________________________

Are you willing to have the agency/person release information to this court? Indicate anyone the court officer may contact who you feel will provide corroboration or information that the court may need: V. INFORMATION REQUIRED FOR CUSTODY: Child(ren)'s present address: Places where the children have lived within the last five years: Address: Address:
3C-P-072
FORM NO. 073936 4/84 Reprograhics (6/08) (Continue on Page

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EXHIBIT PERTAINING TO CONCILIATION, CHILD CARE AND CHILD CUSTODY PROCEEDINGS

EXHIBIT PERTAINING TO CONCILIATION, CHILD CARE AND CHILD CUSTODY PROCEEDINGS (PAGE 2)
NAME and PRESENT ADDRESS of persons with whom the CHILD(REN) has/have lived during that period: NAME: ADDRESS: NAME: ADDRESS: OTHER CUSTODY PROCEEDINGS: 1. Have you participated (as a party, witness, or in any other capacity) in any other litigation concerning your child(ren)'s custody in this or any other state? 2. Do you have information of any custody proceeding concerning the children pending in a court of this or any other state? 3. Do you know of any person not a party to the proceedings who has physical custody of the child(ren) or claims to have custody or visitation rights with respect to the child(ren)? IF YOUR ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, PLEASE PROVIDE THE FOLLOWING: 1. The nature of your participation in other proceedings: 2. The time, place, title of this court, case number and outcome, if any, of the other proceedings: 3. The names of the other persons involved in the other proceedings and their relationship to you: 4. Copies of any court orders in your possession relating to custody/visitation. YES NO

THE UNDERSIGNED SOLEMNLY AND SINCERELY DECLARES, UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF.
DATE SIGNATURE

3C-P-073
FORM NO. 073936 4/84 (Page 2)

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EXHIBIT PERTAINING TO CONCILIATION, CHILD CARE AND CHILD CUSTODY PROCEEDINGS