Self-Help Services can review your completed forms before you file them
with the Court. To request review of your completed forms:
1.
2.
3.
Complete the attached forms in black ink.
Scan your completed forms and save as a single PDF file.
Go to www.occourts.org/self-help (click the blue button labeled Click
Here to Contact Self-Help Services), attach the PDF, and complete the
online request form. Make sure to select PROBATE as the case type
on the form.
DE FACTO PARENT REQUEST
SELF-HELP FORM PACKET
SHC-PB-10 (Rev. 08/05/2021)
www.occourts.org/self-help
SUPERIOR COURT OF CALIFORNIA
COUNTY OF ORANGE
Self-Help Services
www.occourts.org/self-help
WHAT IS A “DE FACTO PARENT?”
A “De Facto Parent” means a person who has been found by the court to have assumed, on a day to day
basis, the role of parent, fulfilling both the child’s physical and psychological needs for care and
affection, and who has assumed that role for a substantial period. (Rule 5.502(10).
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Save This Form
Print This Form
De Facto Parent Request
JV-295, Page 1 of 1
Judicial Council of California, www.courts.ca.gov
Rev. September 1, 2020, Mandatory Form
Cal. Rules of Court, rule 5.534(a)
JV-295
De Facto Parent Request
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
I am/We are asking that I/we be appointed de facto parent(s) of
(Child’s name):
2
The address of any licensed foster family home must remain
confidential unless the judge or the foster parent authorizes release of
the address. Court clerks should not send this page to the parties
without a court order or authorization of the foster parent. (Welf. &
Inst. Code, § 308(a).)
1
My/Our address:
My/Our name(s):
My/Our phone #:
State: Zip:City:
Signature of person requesting de facto parent status
Date:
Type or print your name
Signature of person requesting de facto parent status
Date:
Type or print your name
Signature of attorney (if applicable)
Date:
Type or print attorney’s name
Attorney’s address:
Attorney’s phone #:
State: Zip:City:
NOTICE
If you are not the child, child’s parent, or child’s legal guardian, you may have a right to challenge a decision by the
juvenile court, but only in very limited circumstances. You may need a court order granting you access to records in the
juvenile case file. For more information, please see Information on Requesting Access to Records for Persons With a
Limited Right to Appeal (form ). You can get form at any courthouse or county law library
or online at
JV-291-INFO
JV-291-INFO
www.courts.ca.gov/forms.
Print this form
Clear this form
For your protection and privacy, please press the Clear
This Form button after you have printed the form.
JV-296
De Facto Parent Statement
My/Our name(s):
The child’s name:
Boy Girl
Child’s date of birth:
Age:
Relationship to child (grandparent, foster parent, etc.):
The child has lived with me from:
to (date)
(date)
to (date)
(date)
I have had responsibility for the day-to-day care of the child
from:
Information the judge should know about my relationship with
the child. (This part must be completed).
a. Amount of time I spend with the child (daily, weekly, etc.):
have
d. I
have not
attended
court hearings about the child.
have
e. I
have not sent a written
report to the court about the child.
b. Activities I do with the child:
c. Kinds of information I have about the child that others may not have (medical, educational, behavioral, etc.):
I declare under penalty of perjury under the laws of the State of California that the information on this form is
true and correct to my knowledge. This means if I lie on this form, I am committing a crime.
Date:
Type or print your name
Signature of person requesting de facto parent status
JV-296, Page 1 of 1
Judicial Council of California‚ www.courtinfo.ca.gov
Revised January 1, 2007, Mandatory Form
Cal. Rules of Court‚ rule 5.534(e)
De Facto Parent Statement
to (date)
(date)
to (date)
(date)
Date:
Type or print your name
Signature of person requesting de facto parent status
Clerk stamps below when form is filed.
Court name and street address:
Superior Court of California, County of
Case Number:
1
2
3
4
5
6
7
JV-290-INFO
INSTRUCTION SHEET FOR CAREGIVER INFORMATION FORM
Background
What is the "Caregiver Information Form"? The Caregiver Information Form, also called form JV-290, is intended
to provide an easily accessible way for foster parents, relative caregivers, preadoptive parents, nonrelative extended
family members, legal guardians, community care facilities, and foster family agencies (or any other individual or
agency currently caring for a foster child) to provide information about the child to the court.
When does it need to be filled out and filed? The Caregiver Information Form is an optional form. If you choose
to use it, fill it out and file it with the court along with eight copies, at least five days before the hearing, or mail it to
the court for filing at least seven days before the hearing. Follow the instructions below. Do not wait until the day of
the court hearing to file the form.
Current foster parents, relative caregivers, preadoptive parents, nonrelative extended family members,
legal guardians, and other individuals caring for a child: You may fill out this form even if a staff person from
the child's foster family agency or community care facility is also filling it out. You may write a letter to the court,
instead of using the form. Either way, follow the procedures described on the next page about making copies, filing,
and attending the hearing. Be aware that the form or letter will be provided to parties and attorneys. If you are a
confidential foster parent, provide information to the child's social worker rather than filing the form or letter with the
court.
3.
Complete the caption. These are the boxes at the top of the page.
Court name, street address, and mailing address. Write the name of the county where the court is located and
the street and mailing addresses of the court. If you do not know the name and address of the court, look on the
notice of the court hearing you received in the mail or go to www.courtinfo.ca.gov/courts/find.htm to find the
local court in your county. For branch name, write "Juvenile."
Case Number. This number is on the notice of the court hearing you received in the mail. If you do not have the
number, ask the child's social worker or attorney for the number. If the case involves brothers and sisters
(siblings), there may be more than one case number. Be sure to use a separate form and the correct number
for each child.
Page 1 of 2
Form Approved for Optional Use
Judicial Council of California
JV-290-INFO [New October 1, 2007]
•
•
1.
2.
1.
Foster family agencies or community care facilities: You may complete this form and use it as the mandatory
report required by Welfare and Institutions Code section 366.21. It is recommended that each agency or facility
develop a policy about who is responsible for filling out and filing the form or report on behalf of each child.
4.
What should I be thinking about as I fill out the form? Use the form to provide factual information about the
child, such as behavior you have observed and information about the child's needs. Avoid including opinions or
information not related to the child. The goal is to provide information to the court that helps the judge make
informed decisions about the child.
5.
How to Fill Out Form JV-290
Complete information about the child and about yourself or your agency.
Item 1. Fill in the child's first and last names, date of birth, and age.
Item 2. Foster parents, relative caregivers, and other individuals caring for children should complete item 2.
Include your name, what type of caregiver you are, and how many years and/or months the child has lived in
your home. Skip item 3. If you are a confidential foster parent, provide information to the child's social worker
rather than filing this form with the court.
•
•
2.
Item 3. Foster family agencies, community care facilities, and staff at any other group-care setting should skip
Item 2 and complete item 3. Indicate the facility name, address, telephone number, the type of facility, how
long the child has been with your agency, and how long he or she has been in the current placement. Then
write your name (the person completing form) and your title. If it is not clear from your title, explain in what
capacity you work with the child. Indicate how many hours each week you spend with the child. Finally, check
the box to indicate whether you are filling out the form based on your own observations and recommendations
or on those of a group or team. If applicable, specify the members of the group or team.
•
Child's Name. Write the child's first and last names.
•
INSTRUCTION SHEET FOR
CAREGIVER INFORMATION FORM
Hearing Date and Time. Write the hearing date and time. Ask the social worker if you do not have this information.
•
Welfare and Institutions Code, §§ 366.21; 16010(f)(3);
Cal. Rules of Court, rule 5.534(m)
www.courtinfo.ca.gov
3.
Complete items 4–10 about the child. For each question, check the box to indicate whether there is new
information since the last hearing. Briefly write new information in the appropriate section of the form. Do not
describe anything you have not personally observed.
Item 4. Provide information on the child's medical, dental, and general physical and emotional health (e.g.,
doctor visits, hospitalizations, and medications; descriptions of physical or emotional development).
Item 5. Provide information on the child's status at school, if applicable (e.g., child's grade level; public or
nonpublic school; how the child is doing in school; outcomes of testing or school conferences).
JV-290-INFO [New October 1, 2007]
Page 2 of 2
•
•
Item 6. Indicate whether the child is a special education student and, if so, the date of the most recent
Individualized Education Plan (IEP).
•
Item 7. Provide information on how the child is adjusting to your home/facility (e.g., child's social skills and
behavior at home; how the child is interacting with other family members; how the child expresses feelings and
needs; the child's eating and sleeping patterns).
•
Item 8. Provide information on how the child is getting along with others (e.g., peer relationships, relationships
with teachers and other adults outside of your family).
•
Item 9. Provide information on the child's special interests and activities (e.g., participation in sports or music
lessons; how often the child participates; any talents, interests, or hobbies).
•
Item 10. Provide any additional information that you believe the court should know about the child (e.g.,
behavioral information; services the child is receiving; your recommendations for additional services that are
needed; visitation information, such as dates of visits with parents or siblings).
•
5.
Add any attachments. Check the box in item 12 to add additional pages. You may attach information from the child's
teacher, doctor, or other service providers and a photograph of the child.
6.
Sign and date the form. On the bottom of page 2, write the date, type or print your name, and sign your name.
What to Do With the Form After You Have Filled It Out
2.
If you choose to file the form in person. At least five calendar days before the hearing date, bring the original
form and the recommended eight copies to the court clerk's office at the courthouse where the hearing will be held.
Ask the clerk to file the form for you. Keep one copy of the date-stamped form for yourself. The clerk is responsible
for providing the form to all parties and completing and filing the proof of service form.
1.
Make copies. Caregivers should make eight or more copies of the completed JV-290 form and any attachments.
3.
If you choose to file the form by mail. At least seven calendar days before the hearing date, mail the original form
and all but one of the copies to the court clerk's office at the courthouse where the hearing will be held. Put two
stamps on the envelope. Include a note indicating "For filing and service" and including the case number. The clerk
is responsible for providing the form to all parties and completing and filing the proof of service form.
4.
Confirm the hearing time, date, and place. If you plan to attend the hearing, call the social worker to confirm
the hearing date, time, and courtroom.
What to Do on the Hearing Day
1.
Bring extra copies of the form. If you decide to attend the hearing, it is suggested that you make additional copies
of the form and any attachments in order to provide copies to anyone at the hearing who did not receive them.
2.
Comments in court. If you choose to attend the hearing, any comments you make should be short, factual, and
based on your own observations. You may raise your hand to let the judge know you would like to speak, or let the
courtroom clerk or deputy/bailiff know before the hearing.
JV-290-INFO
INSTRUCTION SHEET FOR CAREGIVER INFORMATION FORM
4.
Recommendation for Disposition (Outcome). If you are a community care facility or foster family agency, you must
include your recommendation for disposition if the JV-290 form is being used as your report required under Welfare
and Institutions Code section 366.21(d). Foster parents and other individual caregivers may include their
recommendation for disposition (outcome) if they choose.
Caregiver Information (Answer only if you are a caregiver, skip #3.):
1. a.
Form Approved for Optional Use
Judicial Council of California
JV-290 [Rev. September 1, 2020]
CAREGIVER INFORMATION FORM
Welfare and Institutions Code, §§ 366.21(c), (d);
Cal. Rules of Court, rule 5.534(k)
www.courts.ca.gov
Page 1 of 2
Child's name:
To the current caregiver, preadoptive parent, community care facility, or foster family agency caring for the child: You may
submit written information to the court, and you may attend review and permanency hearings. You may use this optional
form to provide written information to the court. Please type or print clearly in ink and submit the original and eight copies
of the form to the court clerk's office at least five calendar days (or seven calendar days, if filing by mail) before the
hearing. Be aware that other individuals involved in the case have access to this information. See form JV-290-INFO for
instructions on how to complete this form and file it with the court.
b.
the observations and recommendations of a group or team made up of the following individuals (specify):
(2)
the observations and recommendations of the person filling out this form.
(1)
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
HEARING DATE AND TIME:
CHILD'S NAME:
CAREGIVER INFORMATION FORM
FOR COURT USE ONLY
CASE NUMBER:
JV-290
Child's date of birth:
c.
Child's age:
2.
a. Name of caregiver:
b. Type of caregiver:
Foster parent Relative Legal guardian Preadoptive parent
Nonrelative extended family member
(specify):
Other
c.
The child has been living in my home for (specify): years months.
Agency or Facility Information (Answer only if you are an agency or facility, skip #2.):
3.
a. Name of agency or facility:
d. Type of facility:
Foster family agency Community care agency
(specify):
Other
e.
The child has been placed with our agency/facility for (specify): years months and in the
current home for (specify): years months.
b. Address:
c. Telephone number:
f. Name of person completing form: Title:
g.
Hours per week the person completing this form spends with the child (specify): hours/week.
h. The information on this form consists of
4. Current Status of Child's Medical, Dental, and General Physical and Emotional Health
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows (do not include the names of doctors):
b.
Current Status of Child's Education5.
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows (do not include the names of schools):
b.
(SIGNATURE OF CAREGIVER OR FACILITY/AGENCY STAFF PERSON
WHO HAS COMPLETED THIS FORM)
JV-290 [Rev. September 1, 2020]
CAREGIVER INFORMATION FORM
Page 2 of 2
Date:
JV-290
CHILD'S NAME:
CASE NUMBER:
(TYPE OR PRINT NAME)
Child's Special Education Status6.
The child is a special education student. Date of last Individualized Education Plan (IEP):
a.
The child is not a special education student.
b.
I do not know the child's special education status.
c.
Current Status of Child's Adjustment to Living Arrangement7.
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows:
b.
Current Status of Child's Social Skills and Peer Relationships8.
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows:
b.
Current Status of Child's Special Interests and Activities9.
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows:
b.
Other Helpful Information10.
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows:
b.
Recommendation for Disposition (Outcome) 11.
I have no recommendation for disposition (outcome).
a.
I am recommending the following disposition (outcome):
b.
12.
If you need more space to respond to any section on this form, please check this box and attach additional pages.
Number of pages attached:
NOTICE
If you are not the child, child's parent, or child's legal guardian, you may have a right to challenge a decision by the juvenile court, but
only in very limited circumstances. You may need a court order granting you access to records in the juvenile case file. For more
information, please see Information on Requesting Access to Records for Persons With a Limited Right to Appeal (form JV-291-
INFO). You can get form JV-291-INFO at any courthouse or county law library or online at www.courts.ca.gov/forms
.
Print this form
Clear this form
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This Form button after you have printed the form.
Court name and street address:
Superior Court of California, County of
Case Number:
Clerk stamps date here when form is filed.
(Name):
(Name):
(Child’s name):
asking to be appointed the de facto parent(s) of
orders:
1.
JV-297, Page 1 of 1
De Facto Parent Order
Judicial Council of California, www.courts.ca.gov
Revised September 1, 2019, Mandatory Form
Cal. Rules of Court, rules 5.534(a) and 5.502(10)
JV-297
De Facto Parent Order
does
does not appoint a lawyer to represent the de facto parent.
The court
Date:
COURT WILL FILL OUT SECTION BELOW
The judge, after reading and reviewing the De Facto Parent Request and
the De Facto Parent Statement filed by
The request for de facto parent status is granted.
3.
The judge orders a hearing on the request for de facto parent status.
2.
The request for de facto parent status is denied.
The hearing will take place on
at a.m./p.m. in Department:
of the Superior Court located at
The lawyer’s name is:
(print name)
Judge (or Judicial Officer)
This is a Court Order.
Print this form
Clear this form
For your protection and privacy, please press the Clear
This Form button after you have printed the form.