Placer — Petition for Private CCRC

Source: https://www.placer.courts.ca.gov/sites/default/files/PL-FCS008%20-%20Petition%20for%20Private%20CCRC_July%201%2C%202023%20%28Final%29.pdf

SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER

ATTORNEY OR PARTY WIHOUT ATTORNEY FOR COURT USE ONLY (Name, State Bar Number, 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: PETITION FOR PRIVATE CHILD CUSTODY CASE NUMBER: RECOMMENDING COUNSELING

1. A Request for Order re: child custody and/or child visitation is set for hearing on ____________, at ___________, in department _____.

2. I have been to mediation before: Yes No
   If yes, mediation was provided by Family Court Services, and/or a
   Private Child Custody Recommending Counselor.

   The date of the most recent mediation was ________________________________.

3. I currently have an appointment with Family Court Services: Yes No
   If yes, the date and time of the appointment is _____________ at ___________.

4. Full names and ages of the children for whom I am seeking custody and/or visitation order:

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5. I request that one of the following Private Child Custody Recommending Counselors be
   appointed:
   ______________________________ ______________________________

NOTICE: A Declaration of Private Child Custody Recommending Counselor Regarding Qualifications (local form PL-FCS004) must be attached for each recommending counselor proposed. Declarant shall advance the cost of Private Child Custody Recommending Counseling subject to the court reserving the right to order reimbursement from the other party. 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: _______________________________________

Type or Print Name: _________________________________________

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Form Adopted for Mandatory Use www.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-FCS008 Effective 07-01-2023