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Get CA DCSS 0053 2005-2021

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES VISITATION VERIFICATION DCSS 0053 08/29/05 CSE Case Number Name of person completing form I am the Custodial Party Noncustodial Parent PART 1. SHARED CUSTODY/VISITATION CHECK ONE Shared Custody Visitation Only Neither VISITATION HOURS Regular Visitation From specify day of the week at specify time Circle one a.m./p.m. To specify day of the week Vacation Visitation If Yes please specify dates/times Yes No Summer Visitation Overnight Visitation Court-ordered custody/visitation arrangement Additional Information I declare to the best of my knowledge and belief that the above information is true and correct. I am aware that this information may be provided to the other parent for their verification and that either party may be required to provide documentation. PRINT NAME SIGNATURE DATE. ACTUAL VISITATION BY THE NONCUSTODIAL PARENT INSTRUCTIONS Complete the visitation history for the past 12 months by filling in the last 12 months and number of hours each month the noncustodial parent visited with the child ren. Example If the last 12 months are June 2002 through May of 2003 you will complete June through December on the left side of the chart below. You would put 2002 for the year. Then you would complete the right side of the chart with January through May and put 2003 for the year. MONTH/YEAR NUMBER OF HOURS THE NONCUSTODIAL PARENT VISITED WITH THE CHILD REN EACH MONTH January/ February/ March/ April/ May/ June/ July/ August/ September/ October/ November/ December/ THE NONCUSTODIAL PARENT VISITED WITH THE CHILD REN EACH MONTH TOTAL Page 1 of 2 PART 2. SHARED CUSTODY/VISITATION CHECK ONE Shared Custody Visitation Only Neither VISITATION HOURS Regular Visitation From specify day of the week at specify time Circle one a*m*/p*m* To specify day of the week Vacation Visitation If Yes please specify dates/times Yes No Summer Visitation Overnight Visitation Court-ordered custody/visitation arrangement Additional Information I declare to the best of my knowledge and belief that the above information is true and correct. I am aware that this information may be provided to the other parent for their verification and that either party may be required to provide documentation* PRINT NAME SIGNATURE DATE. ACTUAL VISITATION BY THE NONCUSTODIAL PARENT INSTRUCTIONS Complete the visitation history for the past 12 months by filling in the last 12 months and number of hours each month the noncustodial parent visited with the child ren. Example If the last 12 months are June 2002 through May of 2003 you will complete June through December on the left side of the chart below. Example If the last 12 months are June 2002 through May of 2003 you will complete June through December on the left side of the chart below. You would put 2002 for the year. Then you would complete the right side of the chart with January through May and put 2003 for the year. You would put 2002 for the year. Then you would complete the right side of the chart with January through May and put 2003 for the year. MONTH/YEAR NUMBER OF HOURS THE NONCUSTODIAL PARENT VISITED WITH THE CHILD REN EACH MONTH January/ February/ March/ April/ May/ June/ July/ August/ September/ October/ November/ December/ THE NONCUSTODIAL PARENT VISITED WITH THE CHILD REN EACH MONTH TOTAL Page 1 of 2 PART 2. .

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