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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

FL-105/GC-120

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

                 TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER:

RESPONDENT:

OTHER PARTY:

(This section applies only to family law cases.) 

GUARDIANSHIP OF (Name):

Minor

(This section apples only to guardianship cases.)

CASE NUMBER:

DECLARATION UNDER UNIFORM CHILD CUSTODY 
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)

1. I am a party to this proceeding to determine custody of a child.

2.

My present address and the present address of each child residing with me is confidential under Family Code section 3429 as  
I have indicated in item 3.

3. There are (specify number):

minor children who are subject to this proceeding, as follows: 

(Insert the information requested below. The residence information must be given for the last FIVE years.)

a. Child’s name

Place of birth

Date of birth

Sex

Period of residence

Address

Person child lived with (name and complete current address)

Relationship

to present

Confidential

Confidential

Child's residence (City, State)

Person child lived with (name and complete current address)

Child's residence (City, State)

Person child lived with (name and complete current address)

Child's residence (City, State)

Person child lived with (name and complete current address)

b. Child’s name

Place of birth

Date of birth

Sex

Residence information is the same as given above for child a. 
(If NOT the same, provide the information below.)

Period of residence

Address

Person child lived with (name and complete current address)

Relationship

to present

Confidential

Confidential

Child's residence (City, State)

Person child lived with (name and complete current address)

Child's residence (City, State)

Person child lived with (name and complete current address)

Child's residence (City, State)

Person child lived with (name and complete current address)

to

to

to

to

to

to

c.

d.

Additional residence information for a child listed in item a or b is continued on attachment 3c.
Additional children are listed on form FL-105(A)/GC-120(A). (Provide all requested information for additional children.)

     Form Adopted for Mandatory Use     

Judicial Council of California 
FL-105/GC-120 [Rev. January 1, 2009]

DECLARATION UNDER UNIFORM CHILD CUSTODY 
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)

Page 1 of 2

Family Code, § 3400 et seq.;
Probate Code, §§ 1510(f), 1512
www.courtinfo.ca.gov

SHORT TITLE:

CASE NUMBER:

FL-105/GC-120

4.

Do you have information about, or have you participated as a party or as a witness or in some other capacity in, another court case 
or custody or visitation proceeding, in California or elsewhere, concerning a child subject to this proceeding? 

Yes

No

(If yes, attach a copy of the orders (if you have one) and provide the following information):

 Proceeding

 Case number

Court 
(name, state, location)

Court order
 or judgment 
(date)

Name of each child

Your 
connection to 
the case

Case status

a.          Family

b.          Guardianship

c.          Other

              Juvenile Delinquency/
d.
              Juvenile Dependency

e.           Adoption

 a.            Criminal

 b.            Family 

               Juvenile Delinquency/
c.
               Juvenile Dependency

 d.            Other

 Proceeding

 Case Number

Court (name, state, location)

5.             One or more domestic violence restraining/protective orders are now in effect. (Attach a copy of the orders if you have one
                and provide the following information):

 Court                    

 County           

State

Case number (if known) 

Orders expire (date)

6.

Do you know of any person who is not a party to this proceeding who has physical custody or claims to have custody of or 
visitation rights with any child in this case?

(If yes, provide the following information):

Yes

No

a. Name and address of person

b. Name and address of person

c. Name and address of person

Has physical custody
Claims custody rights
Claims visitation rights

Has physical custody
Claims custody rights
Claims visitation rights

Has physical custody
Claims custody rights
Claims visitation rights

Name of each child

Name of each child

Name of each child

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 DECLARANT)

7.

Number of pages attached:

NOTICE TO DECLARANT: You have a continuing duty to inform this court if you obtain any information about a custody   

proceeding in a California court or any other court concerning a child subject to this proceeding.  

FL-105/GC-120 [Rev. January 1, 2009]

DECLARATION UNDER UNIFORM CHILD CUSTODY 
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)

Page 2 of  2

Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 155
Average fields per page: 77
Reading Level: Grade 7
LIST Grouping(s): FA-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA)

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02