SDSC FLF-028 (Rev. 9/13) DECLARATION IN SUPPORT OF APPLICATION FOR EMERGENCY TEMPORARY ORDER - FAMILY LAW ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA NORTH COUNTY DIVISION, 325 S.

MELROSE DR., VISTA, CA SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA PETITIONER RESPONDENT OTHER PARTY DECLARATION IN SUPPORT OF APPLICATION FOR EMERGENCY TEMPORARY ORDER - FAMILY LAW Requesting Modifying Child Custody/Visitation (Parenting Time) CASE NUMBER 1. There is risk of immediate harm to my child(ren) as defined in Fam. Code § 3064(b). OR There is an immediate risk that my child(ren) will be removed from the State of California. 2. The most recent incident(

s) showing my child(ren) are at risk of immediate harm or immediate risk of being removed from the State of California are: a. Date(

s) of incident(s): b. Description of incident(s): 3. There is not an existing arrangement for custody/visitation (parenting time). There is an existing arrangement for custody/visitation (parenting time) and it will be changed by the requested orders in the following manner: 4. There is a court order. A copy of the order is attached. There is no current custody/visitation order. The child(ren) live with (name): at (address): 5. A completed Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (JC Form #FL- 105) is attached.

A completed Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (JC Form #FL-105) is not attached because there have been no changes since it was last filed. Date: Signature of Petitioner Respondent Other Party