District Court Area of

District No.

............... Applicant

............... Respondent

Instructions for the applicant

Before applying to Court for an order under the Guardianship of Infants Act 1964, it is desirable that you try to reach an agreement with your spouse, civil partner, or any other person who is acting or wishes to act as guardian of the child or children (the “respondent”) about the proposals for the child’s or children’s future. You can attempt to do so by mediation. [If you reach an agreement, you can if you wish jointly agree a more detailed parenting plan for the child or children and attach that plan to this Statement of Arrangements].

Whether you have agreed the proposals or not, you must complete only Parts 1, 2 and 3 of this form and then sign it at the end of Part 3. Please ensure that factual information you give in this form is accurate. You may be asked to swear in court to the truth of your factual answers. The respondent will then complete section 4 or 5 as appropriate. You should take or send the form as completed by you together with a copy to the court office when you issue your application.

Instructions for the respondent

The applicant has completed Part 1, 2 and 3 of this form. Please read all parts of the form carefully.

If you agree with the accuracy of the current arrangements and you agree to the applicant’s proposals for the child or children you should sign Part 4 of the form and strike through Part 5. If you do not agree with the accuracy of the current arrangements and/or with all or some of the proposals, you should strike through Part 4 and complete Part 5 of this form. You should return one copy of the form as completed by you to the applicant or applicant’s solicitor, retaining a copy for your own use.

Information for all parties

The court, in deciding an application under the Guardianship of Infants Act 1964 will regard the best interests of the child as the first and paramount consideration. In such applications, the court may either (a) give such directions as it thinks proper for the purpose of procuring from an expert a report in writing on any question affecting the welfare of the child; or (b) appoint an expert to determine and convey the child’s views, or do both. The court may do so either at the request of a party or without such a request, but having regard to any views expressed by or on behalf of a party or any other person concerned.

Part 1 Details of the child/children

Question 1. Details of child/children

Full name	Date of birth	Name and address of every other parent/ legal guardian /person acting in loco parentis
-	-	-
-	-	-
-	-	-

Question 2. Details of other children (not concerned in this application) of whom either parent is a parent or in loco parentis

Full name	Date of birth	Name of parent/person acting in loco parentis
-	-	-
-	-	-
-	-	-

Part 2 Current arrangements for the child/children

Please give details for each child, if arrangements are different. If necessary, continue on another sheet and attach it to this form.

Current living arrangements

Question 3. Where and with whom does/do the child/children currently live?

Name of child	Lives with	Address
-	-	-
-	-	-
-	-	-

Question 4. Is the place of residence in question 3 rented or owned and, if so, name the tenant(s) or owner(s)

Owned/rented	Name of owner/tenant
-	-

Question 5. Is the rent or mortgage being regularly paid and, if so, by whom?

-

Question 6. Give the names of all other persons living with the children either on a full-time or part-time basis and state their relationship to the children, if any

Name of other person	Living with child(ren) full-time/part-time	Relationship to child(ren)
-	-	-
-	-	-
-	-	-

Question 7. Is this current arrangement agreed by the applicant and the respondent(s)?

Yes/No

If No, please give details in the box below.

-

Current access arrangements

Question 8. What are the current access or contact arrangements between the child/children and the parent(s) or guardian(s) with whom the child/children does not live?

-

Question 9. Have you (the applicant) and the respondent(s) agreed to these current access or contact arrangements?

Yes/No

If No, please give details in the box below.

-

Current care arrangements

Question 10. Who currently cares for the child/children on a day to day basis?

-

Question 11. Have you (the applicant) and the respondent(s) agreed to the current care arrangements for the child/children on a daily basis?

Yes/No

If No, please give details in the box below.

-

Education

Question 12. Give the name(s) of the school, college or place of training attended by the child/children.

Name of child	Name of the school, college or place of training attended	Address	Class/year
-	-	-
-	-	-
-	-	-

Question 13. Do any of the children have any special educational needs?

Yes/No

If Yes, please give details in the box below.

-

Details of health

Question 14. Are the children generally in good health and without any special health needs?

Yes/No

If No, please give details of any disability, chronic illness, or the care needed and how it is to be provided, in the box below.

-

Court proceedings concerning the child/children

Question 15. Are there, or have there been, any proceedings in any court (in Ireland or elsewhere) involving or affecting the child/children, for example:

a) guardianship or access proceedings?

b) maintenance?

c) child care?

d) adoption?

e) wardship?

f) domestic violence (e.g. barring order or safety order concerning the place where the child/children live)?

Yes/No

If Yes, please give details in the box below. Please include information about any current proceedings in the family courts.

-

Question 16. If there is a maintenance order in place providing for maintenance of the child/children, please provide details below

Name of child	Name and address of the person ordered to pay maintenance	Amount payable weekly
-	-	-

Question 17. Are any of the children in the care of the Child and Family Agency (Tusla) or under the supervision of a social worker or probation officer?

Yes/No

If Yes, please give details in the box below.

-

Question 18. Are any of the children the subject of a community sanction issued by the Children Court?

Yes/No

If Yes, please give details in the box below

-

Mediation

Question 19. If you are not agreed as to the arrangements for the child/children, do you intend to:

• attempt to agree matters with the respondent(s) directly before coming to court?

Yes/No

• propose the use of Alternative Dispute Resolution such as mediation?

Yes/No

If No, would you agree to use Alternative Dispute Resolution such as mediation?

Yes/No

Question 20. Do you have a view on whether the Court should seek an expert report on any question affecting the welfare of the child/children?

Yes/No

If Yes, give details

-

Question 21. Do you have a view on whether the Court should appoint an expert to determine and convey the child’s/children’s views?

Yes/No

If Yes, give details

-

Part 3 Applicant’s proposed arrangements for the child/children

Proposed living arrangements

Question 22. What arrangements are you requesting about where and with whom the child/children live in your application?

Name of child	Proposed to live with	Address
-	-	-
-	-	-
-	-	-

Question 23. Is this proposed arrangement agreed by the applicant and the respondent(s)?

Yes/No

If No, please give details in the box below.

-

Proposed access arrangements

Question 24. What are the access or contact arrangements between the child/children and the parent(s) or guardian(s) with whom the child does not live you are requesting the court to make?

-

Question 25. Have you (the applicant) and the respondent(s) agreed to these proposed access or contact arrangements?

Yes/No

If No, please give details in the box below.

-

Proposed care arrangements

Question 26. Who do you propose the court should order will care for the child/children on a day to day basis?

-

Question 27. Have you (the applicant) and the respondent(s) agreed to the proposed care arrangements for the child/children on a daily basis?

Yes/No

If No, please give details in the box below.

-

Signed: ...........
Applicant

Name (BLOCK CAPITALS):

Date:

Part 4 To be completed where respondent agrees

I agree with the accuracy of the current arrangements for the child/children as set out at Parts 1 and 2 above and I agree to the applicant’s proposals for the child/children as set out at Part 3 above.

Signed: ...........
Respondent

Name (BLOCK CAPITALS):

Date:

Part 5 To be completed where respondent does not agree

Current arrangements for the child/children

If you do not agree with some of the information given above in the answers to questions 1 to 18 inclusive concerning the current arrangements for the child/children, please set out below the answers you dispute and your answers to these questions.

Question number	Respondent's answer

Respondent’s proposed arrangements for the child/children

Proposed living arrangements

What arrangements are you requesting about where and with whom the child/children live?

Name of child	Proposed to live with	Address
-	-	-
-	-	-
-	-	-

Proposed access arrangements

What are the access or contact arrangements between the child/children and the parent(s) or guardian(s) with whom the child does not live you are requesting the court to make?

Proposed care arrangements

Who do you propose the court should order will care for the child/children on a day to day basis?

-

Do you wish to ask the Court to give directions for the purpose of procuring an expert report on any question affecting the welfare of the child/children?

Yes/No

If Yes, give details

-

Do you wish to ask the Court to appoint an expert to determine and convey the child’s/children’s views?

Yes/No

If Yes, give details

-

Signed: ...........
Respondent

Name (BLOCK CAPITALS):

Date: