Free Parent Child Relationship Declaration (FL/E-LP-616) - California

Parent-Child Relationship Declaration (Family Code Section 6323)
Case Name ___________________________________ I, ___________________________________, declare: (print name of declarant) I am the father/mother and the other party is the father/mother of the following child(ren): (circle one) (circle one) ______________________________________ ______________________________________ ______________________________________ Date of Birth_________________ Date of Birth_________________ Date of Birth_________________ Case Number________________

CHECK THE STATEMENT(S) THAT APPLY TO YOU: 1. 2. _____ _____ I gave birth to (all of) the child(ren). The child(ren) was/were born during marriage/domestic partnership or within 300 days after separation. I/we adopted the child(ren) or are in process of adoption the child(ren). I have/the other party has signed a valid declaration of paternity. The Juvenile Court has made a determination that there is a parent-child relationship between the father and the child(ren)/mother and the child(ren). A court has determined paternity in a local child support agency case where custody and/or visitation was an issue. I have been determined to be the parent of the child(ren) through a Uniform Parentage Act court order. There are current Child Custody and Visitation orders as follows: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

3. 4. 5.

_____ _____ _____

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8.

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I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:_______________________ ______________________________________________ Signature of Declarant
Parent-Child Relationship Declaration Page 1 Family Code 6323

FL/E-LP-616 (REV. 02.26.07) MANDATORY