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Please check this box to acknowledge you understand that upon acceptance of this report, NO FURTHER ACTION WILL BE TAKEN by the San Diego County District Attorney's Office. Should you need assistance in pursuing a civil enforcement remedy, contact a private attorney or the Family Law Facilitator for assistance. After you complete this report, it will be kept on file with this office. If you need a copy of the report for a court proceeding, you may direct a subpoena for records only to the following: District Attorney's Office, 330 W. Broadway, Suite 1220, San Diego, CA 92101

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Your Name / Date of Birth / Email Address
  Last:   First:   Middle:   DOB:
Email:

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Your Street Address / City / State / ZIP
Number/Street:   City:   State: - Select State - ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING   Zip:

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Your Contact Numbers
Home:   Other:   Work Cell Message

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Your Relationship To The Child
Mother Father Legal Guardian Other - Specify  

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Child Information - Name / Date of Birth
Child 1 - Last:   First:   Middle:   DOB:
Child 2 - Last:   First:   Middle:   DOB:
Child 3 - Last:   First:   Middle:   DOB:

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Person Violating Order - Name / Date of Birth
Last:   First:   Middle:   DOB:

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Person Violating Order - Street Address / City / State / ZIP
Number/Street:   City:   State: - Select State - ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING   Zip:

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Person Violating Order - Contact Numbers
Home:   Other:   Work Cell Message

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Person Violating Order - Relationship To The Child
Mother Father Legal Guardian Other - Specify  

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When Did You Last See Your Child/Children?       Have You Reported Other Visitation Violations To The DA's Office?
                        Yes No     Case Number:

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Family Court Information
Family Court Case No.:   Name of Court:   Date of Current Visitation Order:

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You Have:   Visitation   Supervised Visitation      Joint Legal Custody   Joint Physical Custody
                     Sole Physical Custody   Guardianship   Other - Specify  

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What is the specific visitation arrangement ordered by the court?

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Explain how the violation occurred. Include date(s), time(s) and location(s):

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I agree and understand that by submitting this form I am declaring under penalty
of perjury that the information I supplied is true and correct.