NAME OF APPLICANT:
ADDRESS OF APPLICANT:
 
TELEPHONE NO.:
RELATIONSHIP TO CHILD:
 

1. I am requesting the Court declare that I am the de facto parent of the child.
    
2. I had responsibility for the day-to-day care of the child from __________________ to ____________________________.
    
3. The child lived with me from _________________ to ____________________.
    
4. Other information the Court should know about my relationship with the child:
    
    
    
    
    
    
5. I am requesting an attorney be appointed to represent me if I am declared to be a de factoparent. Yes___ No___

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)               (Signature of Petitioner)