Placer — Declaration of Private Mediator or CCRC Regarding Qualifications

Source: https://www.placer.courts.ca.gov/sites/default/files/pl-fcs004.pdf

SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER

MEDIATOR OR RECOMMENDING COUNSELOR FOR COURT USE ONLY (Name and Address):

TELEPHONE NO.: Superior Court of California, County of Placer 10820 Justice Center Drive 2501 N. Lake Blvd. P. O. Box 619072 P.O. Box 5669 Roseville, CA 95661-9072 Tahoe City, CA 96145 Petitioner/Plaintiff:

Respondent/Defendant: DECLARATION OF PRIVATE MEDIATOR OR CHILD CUSTODY CASE NUMBER: RECOMMENDING COUNSELOR REGARDING QUALIFICATIONS

1. I, (name) : ____________________________________ , declare that if I appeared in court and

   were sworn, I would testify to the truth of the facts in this declaration.

2. On (date):_______________________ , I was appointed by the court to perform a mediation or child custody recommendation in this case.

3. I am licensed as a psychologist, marriage and family therapist, or clinical social worker.

4. I submit this form to indicate compliance with applicable requirements for a private mediator or child custody recommending counselor under rule 5.210 and rule 5.230 of the California Rules of Court at the time of my appointment in this case.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: ________________ (Type or print name) SIGN

(Signature of declarant)

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Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-FCS004 Effective 07-01-2017