Petition to Establish (SAPCR — Statewide) — Children

a. Children's Basic Information

Child's name Write the full name of the first child you want the Court to make orders about. Date of Birth Write the first child's date of birth. County and State where child lives now Write the county and state where the first child lives now. Child's name Write the full name of the second child, if there is one. Date of Birth Write the second child's date of birth. County and State where child lives now Write the county and state where the second child lives now. Child's name Write the full name of the third child, if there is one. Date of Birth Write the third child's date of birth. County and State where child lives now Write the county and state where the third child lives now. Child's name Write the full name of the fourth child, if there is one. Date of Birth Write the fourth child's date of birth. County and State where child lives now Write the county and state where the fourth child lives now. Child's name Write the full name of the fifth child, if there is one. Date of Birth Write the fifth child's date of birth. County and State where child lives now Write the county and state where the fifth child lives now. ________________________________________ Use these lines to finish any details from the section above this page.

b. Possession & Access

One or more of the children is under age 3. Until the child turns 3, possession should be as follows: Check this box if any of your children is younger than 3 years old. A different schedule is often needed for very young children. Until the child turns 3, possession should be as follows: Describe the visit schedule you want while the child is under age 3, such as how often and how long each parent has the child. I am concerned about the safety of the children with: Check this box if you worry the children are not safe with the other parent. Father Check this box if you are worried about the children's safety with the father. Mother Check this box if you are worried about the children's safety with the mother. exchanges of the children be supervised, or in the alternative, be in a public place Check this box if you want another person to watch when the children are handed off, or for the handoff to happen somewhere public. that parent's possession of the children be limited to day visits Check this box if you want that parent's visits to happen only during the day, with no overnight stays. that parent's possession of the children be supervised Check this box if you want another person present during that parent's time with the children. that parent have no right to possession or access to the children Check this box if you want that parent to have no visits or contact with the children. that parent be ordered not to use alcohol or illegal drugs 24 hours prior to or during possession of the children. Check this box if you want that parent ordered not to use alcohol or illegal drugs before or during their time with the children. that parent's possession and access to the children be restricted as follows: Check this box if you want other limits on that parent's time with the children that are not listed above. that parent's possession and access to the children be restricted as follows: Explain the specific limits you want on that parent's visits or contact with the children. I am concerned that the other parent may take the child(ren) to another country and refuse to return them. I ask the Court to determine if there is a risk of international kidnapping by the other parent and to take such measures as are necessary to protect the child(ren). Check this box only if you fear the other parent may take the children to another country and not bring them back. The child(ren) do not own any property of significant value in their own name. Check this box if the children do not own any valuable property in their own names. The child(ren) own the following property of significant value in their own name: Check this box if the children own valuable property in their own names, then describe it below. The child(ren) own the following property of significant value in their own name: ____ Describe the valuable property the children own, such as savings, land, or a vehicle.

c. Health & Medical Support

have private health insurance. Check this if the children are covered by private health insurance, not a government program. Name of insurance company: Write the name of the company that provides the children's health insurance. Policy number: Write the policy number found on the insurance card or paperwork. Cost of premium: $ Write how much is paid for the insurance each month. Name of person who pays for insurance: Write the name of the person who pays for the children's health insurance. The insurance policy is available through the parent's work. Check this if a parent can get the insurance through their job. The insurance policy is not available through the parent's work. Check this if the insurance is not offered through a parent's job. have health insurance through Medicaid. Check this if the children are covered by Medicaid, a government health program. have health insurance through C.H.I.P. Check this if the children are covered by CHIP, a low-cost government health program for kids. Cost of premium (if any): Write the monthly cost for CHIP, if there is one. Leave blank if free. do not have health insurance. Check this if the children have no health insurance at all. Private health insurance is available to Father at a reasonable cost. Check this if the father can get private health insurance for the children at a fair price. Private health insurance is not available to Father at a reasonable cost. Check this if the father cannot get private health insurance at a fair price. Private health insurance is available to Mother at a reasonable cost. Check this if the mother can get private health insurance for the children at a fair price. Private health insurance is not available to Mother at a reasonable cost. Check this if the mother cannot get private health insurance at a fair price. have private dental insurance. Check this if the children are covered by private dental insurance. Name of insurance company: Write the name of the company that provides the children's dental insurance. Policy number: Write the dental policy number from the insurance card or paperwork. Cost of premium: $ Write how much is paid for the dental insurance each month. Name of person who pays for insurance: Write the name of the person who pays for the children's dental insurance. The insurance policy is available through the parent's work. Check this if a parent can get the dental insurance through their job. The insurance policy is not available through the parent's work. Check this if the dental insurance is not offered through a parent's job. do not have dental insurance. Check this if the children have no dental insurance at all. Private dental insurance is available to Father at a reasonable cost. Check this if the father can get private dental insurance for the children at a fair price. Private dental insurance is not available to Father at a reasonable cost. Check this if the father cannot get private dental insurance at a fair price. Private dental insurance is available to Mother at a reasonable cost. Check this if the mother can get private dental insurance for the children at a fair price. Private dental insurance is not available to Mother at a reasonable cost. Check this if the mother cannot get private dental insurance at a fair price. have Medicaid now or had in the past. Check this if the children get Medicaid now or got it before. This affects who you must notify. get TANF (Temporary Assistance for Needy Families) now or got it in the past. Check this if the children get TANF cash assistance now or got it before. This affects who you must notify.