Notice of Residential Parent’s Intent to Relocate – Fairfield County Domestic Relations Division

Case Number Residential Parent Name Residential Parent Address line 1 Residential Parent Address line 2 Residential Parent Date of Birth Non-Residential Parent Name Non-Residential Parent Address line 1 Non-Residential Parent Address line 2 Non-Residential Parent Date of Birth Child 1 name Child 1 date of birth Child 2 name Child 2 date of birth Child 3 name Child 3 date of birth Child 4 name Child 4 date of birth Child 5 name Child 5 date of birth Residential Parent Name in statement Current residence line 1 Current residence line 2 Move date Move year New address option A line 1 New address option A line 2 Prior entry filed on Residential Parent Signature Phone Date