Declaration Alleging Domestic Violence {FCS-017}

SDSC FCS-017 (Rev. 8/15) DECLARATION ALLEGING DOMESTIC VIOLENCE Fam. Code 247 3181 Mandatory Form FOR SEPARATE FAMILY COURT SERVICES SESSION SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST ., SAN DIEGO, CA 92101 CENTRAL DIVISION, FAMILY COURT, 1555 6TH AVE., SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 DECLARATION ALLEGING DOMESTIC VIOLENCE Petitioner Case No. Respondent FCS Date A PARTY ALLEGING A HISTORY OF DOMESTIC VIOLENCE AND NOT COVERED BY A PROTECTIVE ORDER MAY REQUEST A SEPARATE MEETING TIME WITH A FAMILY COURT SERVICES COUNSELOR BY COMPLETING THIS FORM. COMPLETE AND RETURN THIS FORM TO FAMILY COURT SERVICES AT THE ADDRESS CHECKED ABOVE. I, , am the petitioner respondent in the above-entitled case. I request a separate meeting with the Family Court Services Child Custody Recommending Counselor as authorized in Fam. Code 247 3181 because of a history of domestic violence with the other party. Fam. Code 247 6203 defines abuse as: 1. Intentionally or recklessly to cause or attempt to cause bodily injury. 2. Sexual assault. 3. To place a person in reasonable apprehension of imminent serious bodily injury to that person or to another. 4. To engage in any behavior that has been or could be enjoined Molesting Attacking Striking Stalking Threatening Harassing Assaulting (sexual or otherwise) Credibly impersonating (on the Internet, electronically or otherwise) as described in Pen. Code 247 528.5 Falsely personating as described in Pen. Code 247 529 Telephoning, including, but not limited to, making annoying telephone calls as described in Pen. Code 247 653m Destroying personal property Contacting, either directly or indirectly, by mail or otherwise Coming within a specified distance Disturbing the peace of the other party I declare under penalty of perjury under the laws of the State of California that I have been a victim of abuse, as defined in Fam. Code 247 6203. Date: Signature of Declarant American LegalNet, Inc. www.FormsWorkFlow.com