Child Abduction Form - Imperial County District Attorney

Person who has the child/ren (physically)

First Name *

Middle Name

Last Name *

Former Address

City *

State/Province *

ZIP / Postal Code

Phone Numbers

Home

Work

Message

Address where child/ren is or will be concealed until the Court Hearing

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

Date of Birth

Age

Race

Gender *MaleFemale

Hair

Eyes

Height

Weight

Social Security Number

Relationship to child/ren *

Driver's License Number

DL State

Name of Attorney

Attorney Phone Number

Employer (or Last Employer) Name

City

State/Province

ZIP / Postal Code

Phone

Has Child Protective Services ever been involved? *YesNo

Name of CPS Worker

County

Phone

Have you ever been arrested? (Charge, City and Date)

Have you ever been charged or investigated for a crime against or involving a child/ren (Child Abuse, Child Neglect)? Charge, City, Date

Are there any previous or current custody orders related to the child/ren listed below? If yes, State/Court/case Number

Child/ren Information

Child 1

First Name *

Middle Name

Last Name *

Date of Birth

Age

Gender *MaleFemale

Last School Attended

Doctor

Phone

Child 2

First Name *

Middle Name

Last Name *

Date of Birth

Age

Gender *MaleFemale

Last School Attended

Doctor

Phone

Child 3

First Name *

Middle Name

Last Name *

Date of Birth

Age

Gender *MaleFemale

Last School Attended

Doctor

Phone

Note:

If listing more than 3 children, Attach a document with their information

AttachmentsAttach documents if required

No file chosen

Describe any arrests, investigations by Police or Child Protective Services where this person is accused of any crime against or involving children. (Dates, City, Agency involved, etc)

Arrest for other crimes

Have you filed or are there any current restraining Orders (TRO) related to any of the parties? if yes, court case number

This portion must be filled out completely

Describe in detail the bodily injury or emotional harm that threatened the child/ren

Any Person who signs this statement and who willfully states as true any material matter which he knows to be false is subject to the criminal penalties prescribed by law for perjury.

I declare under penalty of perjury the information on this form is true and correct.

Executed at:

City

State/Province

Name of person filling up this form *

Imperial County

District Attorney's Office

Child Abduction Report Form

Person who has the child/ren (physically)

Former Address

Phone Numbers

Address where child/ren is or will be concealed until the Court Hearing

Child/ren Information

Child 1

Child 2

Child 3

Note:

If listing more than 3 children, Attach a document with their information

This portion must be filled out completely

Any Person who signs this statement and who willfully states as true any material matter which he knows to be false is subject to the criminal penalties prescribed by law for perjury.

I declare under penalty of perjury the information on this form is true and correct.

Executed at: