IN THE CIRCUIT COURT OF (YOUR COUNTY), (YOUR STATE)

(OTHER CUSTODIAL PARENT’S FULL NAME) vs. (YOUR FULL NAME)

(YOUR COUNTY) COUNTY FRIEND OF THE COURT (OR YOUR STATE’S

EQUIVILENT) CASE# (ENTER CASE #)

NOTICE OF INTENT TO EXERCISE PARENTAL RIGHT FOR ADDITIONAL

PARENTING TIME

USPS CONFIRMATION# 0308 0070 XXXX XXXX XXXX

YOU ARE ADVISED that (YOUR NAME) intends to Exercise his parental rights with his
child, (CHILD OR CHILDREN’S NAME) in the following matter.

1. The children shall spend from (DAY) evening at (TIME)p.m. to (TIME) p.m. (DAY) evening
on (PICK UP DATES EXAMPLE: July 22nd and 23rd).

2. Place of pick-up and return shall be (ADDRESS, CITY, STATE).

3. The children will need the appropriate changes of clothing and health care items for a
overnight visitation.

4. During the exercise of the above time schedule, the children shall be located within the bounds
of the (YOUR COUNTY) area.

5. Basis for the exercise of parental rights: Order granted by Judge (JUDGES NAME) on (DATE
OF VISITATION ORDER, YEAR).

AS NOTICE HEREOF, The original of this Notice Of Intent To Exercise Parental Rights has
been filed with the Court, and true copies have been mailed as indicated below. YOU ARE
REQUESTED TO COOPERATE in permitting the Respondent to exercise his lawful parental
rights and to notify the Respondent listed below and the Court in writing prior to the date of
exercise if there is some legal reason why these rights, as set forth, cannot be exercised at the
date, time, place, and in the particulars described.

Respondent:

(YOUR NAME)
Your address
TEL: (xxx) xxx-xxxx

Original copy mailed and filed (DATE) with:

Clerk of Court (or your state’s equivalent)

Address
and copies mailed the same date to:

(YOUR COUNTY) County Friend of the Court(OR EQUIVALENT)

Address

Plaintiff:

(OTHER PARTY’S FULL NAME)

Address
TEL: (xxx) xxx-xxxx
Last Known Attorney for Plaintiff: (ATTORNEY’S NAME), P.L.L.C.

USPS DELIVERY CONFIRMATION #:XXXX XXXX XXXX XXXX XXXX

** **F or fu ll inst r uc tions on ho w to use this

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