C100

Applicant(s) Name

First name Last name

Respondent(s) Name

First name Last name

Concerns about risk of harm

Are you alleging that the child(ren) named in Section 1 of this form have experienced, or are at risk of experiencing, harm from any of the following by any person who has had contact with the child?

any form of domestic abuse

Yes

child abduction

Yes

child abuse

Yes

drugs, alcohol or substance abuse

Yes

other safety or welfare concerns

Yes

The Child(ren)

Child 1 - Name

First name(s) Last name

Regarding Child 1's birth date

I don’t know date of birth of child 1

Child 1 - Date of birth

Child 1 - Gender

Female

Male

Other

Applicant(s) relationship to the child 1

Respondent(s) relationship to the child 1

Child 2 - Name

First name(s) Last name

Regarding Child 2's birth date

I don’t know date of birth of child 1

Child 2 - Date of birth

Child 2 - Gender

Female

Male

Other

Applicant(s) relationship to the child 2

Respondent(s) relationship to the child 2

Child 3 - Name

First name(s) Last name

Regarding Child 3's birth date

I don’t know date of birth of child 1

Child 3 - Date of birth

Child 3 - Gender

Female

Male

Other

Applicant(s) relationship to the child 3

Respondent(s) relationship to the child 3

Child 4 - Name

First name(s) Last name

Regarding Child 4's birth date

I don’t know date of birth of child 1

Child 4 - Date of birth

Child 4 - Gender

Female

Male

Other

Applicant(s) relationship to the child 4

Respondent(s) relationship to the child 4

Are any of the children known to the local authority children’s services?

Yes

Don’t know

Please state everyone who has parental responsibility for each child and how they have parental responsibility (e.g. ‘child’s mother’, ‘child’s father and was married to the mother when the child was born’ etc.)

Who do the children currently live with?

Applicant(s)

Respondent(s)

Other

Please give brief details:

• any previous agreements (formal or informal) or parenting plans, and how they have broken down • your reasons for bringing this application to the court • what you want the court to do • reasons given by the respondent(s) for their actions in relation to this application.

Have you previously prepared a Parenting Plan?

Yes

If No, you can download a copy from the website www.cafcass.gov.uk/parentingplan . If Yes, please attach the plan to this application form

Other court cases which concern the child(ren) listed Above

Complete this section if you have ticked the relevant box on the front of this form. Use this section to provide details of any other court cases now, or at any time in the past, which concern any of the child(ren) listed in section 1.

Name of child(ren)

Name of the court where proceedings heard

Case no.

Date/year (if known)

Name and office (if known) of Cafcass/CAFCASS CYMRU officer

Do you or any of the parties require the court to appoint an interpreter or arrange any other assistance (e.g. sign language)?

Yes

If Yes, who requires the interpreter

applicant

respondent

Other party

Please specify other party

Please specify the language and dialect required

If attending the court, do you or any of the parties involved have a disability for which you require special assistance or special facilities?

Yes

If Yes, please say what the needs are

About you (the applicant)

Name

First name(s) Last name(s)

Previous names (if any)

Gender

Male

Female

Date of birth (If under 18 read section Q of leaflet CB1)

Place of birth

(town/county/country)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home telephone number

Mobile telephone number

Email address

Have you lived at this address for more than 5 years?

Yes

If No, please provide details of all previous addresses you have lived at for the last 5 years.

The respondent(s)

Fill respondent's detail on below field.

Name

First name(s) Last name(s)

Previous names (if any)

Gender

Male

Female

Date of birth (If under 18 read section Q of leaflet CB1)

Place of birth

(town/county/country)

Address (to which documents relating to this application should be sent)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home telephone number

Mobile telephone number

Email address

Have they lived at this address for more than 5 years?

Yes

Don’t know

If No, please provide details of all previous addresses for the last 5 years below (if known, including the dates and starting with the most recent)

Court fee – Are you paying the court fee by credit or debit card?

Yes, the court will contact you, using the details given in your application, within three working days to take payment

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C100 Form

Concerns about risk of harm

The Child(ren)

Other court cases which concern the child(ren) listed Above

About you (the applicant)

The respondent(s)