In Re the Matter of: Hague Petition for ] No. [Case Number]

Summary Return of Child Wrongfully ]

Removed and/or Wrongfully Retained ]

] INTERNATIONAL

Petitioner: [Name] ] REQUEST FOR

] ASSISTANCE;

and ] ORDER FOR RETURN

] OF CHILD AND FOR

Respondent: [Name] ] INTERIM CARE OF

_________________________________________] MINOR CHILD

The Convention on the Civil Aspects

of International Child Abduction,

done at the Hague on 25 Oct 1980 [The Convention]

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International Child Abduction Remedies Act

42 U.S.C. 11601 et seq.

1.1 This court, in the letter and spirit of The Convention on the Civil Aspects of International Child Abduction, done at the Hague on 25 Oct 1980 (The Convention) extends its greetings to the [Name of Responding Country] and respectfully submits its order for the interim care and custody of the minor child of the parents to the [Name of Responding Country].

1.2 The court assures the [Name of Responding Country] that the well being of the minor child shall be its paramount concern at all times and that all steps shall be taken to safeguard the health and safety of the minor child. This court will, at the appropriate time, provide all of its services to both parties, including, but not limited to, the Court's Social Service Agency.

1.3 This Court stands ready to consider any request from the [Name of Responding Country] concerning the minor child.

1.3.1 Should the courts or other agencies of the [Name of Responding Country] wish to do so, they may contact the Court of [State] [Enter Telephone and/or FAX number of the issuing court.].

2.1 This Court, upon review of the evidentiary information submitted by the Petitioner [Name of Petitioner], makes the following findings:

2.1.1 The State of [State] has personal jurisdiction over both [Name of Petitioner] and [Name of Respondent] in that both parties were domiciled in the State of [State] during the term of their [marriage, relationship].

2.1.2 The State of [State] has Child Custody Subject Matter Jurisdiction (CCSMJ) pursuant to 9 Uniform Laws Annotated [ULA] 3(a)(1) [Enter the appropriate code section, e.g., for California: Family Code Section (F.C.) 3403(a)(1)], commonly called "Home State" CCSMJ or, in the alternative, pursuant to 9 ULA 3(a)(2) [e.g., for California: F.C. 3403(a)(2)], commonly called "Significant Connections" CCSMJ.

2.1.3 The minor child of the parties has lived in [State] [Enter the date(s) that the child lived in the State] until his removal from [State] on [Date of removal and/or retention]. [If appropriate]: The Court further finds that the occasional trips from [State]to the [Name of Responding Country] by [Name of party, usually the Respondent] and the child are "Temporary Absences" within the meaning of 9 ULA 2(5) [e.g., for California: F.C. 3402(e)]. Accordingly this Court finds that [State] is the "Habitual Residence" of the minor child [Name of Minor Child], dob [dd mmm yyyy] within the meaning of Article 3 of The Convention.

2.1.4 Pursuant to [Enter code section of State that gives the parents joint custody absent a court order, e.g., California: F.C. 3010], a copy of which is attached as an Exhibit __ , both parents, absent an order of a Court of competent jurisdiction, have equal rights of custody. Accordingly this Court finds that [Name of Petitioner] had and continues to have a "Right of Custody" within the meaning of Articles 3 and 5 of The Convention.

2.1.5 The Court finds that [Name of Minor Child] was removed from [State] on [Date of removal and/or retention] without the knowledge or consent of the Petitioner [Name of Petitioner] and that this removal was in derogation of [Name of Petitioner's] rights of custody. Accordingly, pursuant to Article 15 of The Convention, this Court finds that the removal of [Name of Minor Child] from [State] by [Name of Respondent] was and is a "Wrongful Removal". At the time of [Name of Minor Child]'s removal, [Name of Petitioner] was exercising his rights of custody jointly with [Name of Respondent].

2.1.6 The efforts made by Petitioner [Name of Petitioner] to cause the return of [Name of Minor Child] to his "Habitual Residence" are in conformity with Article 7(c) of The Convention, which is to secure the voluntary return of [Name of Minor Child]. Accordingly this Court finds that at no time from [Date of removal and/or retention] to the present has there been acquiescence by [Name of Petitioner] to the wrongful removal by [Name of Respondent] within the meaning of Article 13(a) of The Convention.

2.1.7 [If appropriate]: The Court, after careful consideration of the evidentiary information supplied by [Name of Petitioner], finds that there is a high risk that [Name of Respondent] will, if notified of these proceedings, take steps to conceal his/her and the child's whereabouts from [Name of Petitioner] and/or the legal systems of [Name of Responding Country] and/or [State].

3.1 All existing actions before this Court are stayed except as set forth below.

3.2 Upon the ordering of the return of the minor child to [State], the following orders shall be in full force and effect, without prejudice to either parent, pending further hearing in the Court of [State].

3.3 Both parents are ordered to take all immediate steps to cause the return of [Name of Minor Child] to [State] forthwith.

3.4 Within five (5) court days after the day that [Name of Minor Child] returns to [State] both parties and the child are ordered to be present for a de novo hearing before this court on the interim care, custody and control of [Name of Minor Child].

3.5 [If Appropriate, e.g., there is a substantial risk of flight on the part of the removing parent] The Courts of the [Name of Responding Country] are respectfully requested to issue orders for the immediate pickup of the minor child prior to or simultaneously with any notice given to [Name of Respondent] of hearings to be conducted in the [Name of Responding Country] on [Name of Petitioner's] Request for Return under The Convention. 3.5.1 This Court, based on the above, finds that, at this time, it would not be in the best interests of the minor child to be in the care and control of [Name of Respondent], respectfully requests that, pending further hearing in this Court, no award of custody of the minor child be made to [Name of Respondent].

3.5.2 This Court further respectfully requests that the child either be cared for by the [Name of Responding Country's] [Name of Child protection agency] or, alternatively, be placed in the interim care of [Name of Petitioner], subject to any conditions of the Courts of the [Name of Responding Country].

3.5.3 This Court will enforce any orders issued by the [Name of Responding Country] for the interim care of the minor child.

3.6 Once [Name of Minor Child] has been returned to [State], no person shall remove him/her from [State] without the express written order of this Court.

3.7 [If Appropriate] Petitioner shall provide Respondent and the minor child a suitable place to reside in [State] pending further hearing of the Court in [State].

3.8 [If Appropriate] Petitioner shall provide Respondent with suitable means of transportation in [State] pending further hearing of the Court in [State].

3.9 [If Appropriate] Petitioner shall pay Respondent reasonable family support in an amount to be determined by the Court in [State].

3.10 [If Appropriate] Petitioner shall provide reasonable travel expenses from [Country] to [State] for Respondent and the minor child.

4.1 Both parties are enjoined and restrained from doing any of the following:

4.1.1 Harassing, molesting or disturbing the peace of the the other or contacting the other at their residence or place of employment except regarding arrangements for their minor children or in an emergency.

4.1.2 Removing the minor child from the jurisdiction of the court except upon prior order of the court or the prior written consent of the other party.

4.1.3 Petitioner and Respondent must stay at least 100 meters away from each other and the following places:

Their respective residences, their respective place of work, (other places as appropriate).

4.1.4 [Other mutual restraining orders as required for the particular situation.]

5.1 Upon review of the above and for GOOD CAUSE SHOWN, the Court hereby orders that both parties are to comply with the above in all respects.

Date: ____________________________________

Judge of the [Circuit, Superior] Court

County of [Name of County]

State of [State]

United States of America