Form GEN 853, Declaration Completed Form Examples and Samples
Find clear, filled-out examples and samples of Form GEN 853, Declaration. Our detailed guide provides completed GEN 853 forms to help you understand how to properly fill out this essential California court document for your legal case.
Form GEN 853, Declaration Example for Child Custody Modification
How this form was filled:
This is a sample of a filled-out Form GEN 853 used in a California family law case. The declarant, Jane A. Smith, is representing herself ('In Pro Per') and is providing factual statements to the court to support her request to modify an existing child custody order. The form includes the case details, numbered statements, and is properly signed and dated.
Information used to fill out the document:
- Attorney For: In Pro Per
- Declarant's Name: Jane A. Smith
- Court Name: Superior Court of California, County of Los Angeles
- Case Name: Jane A. Smith vs. John C. Doe
- Case Number: FAM123456
- Declaration Topic: Declaration of Jane A. Smith in Support of Request to Modify Child Custody
- Hearing Date: August 10, 2026
- Hearing Time: 9:00 AM
- Department: 42
- Statement 1: I am the petitioner in this matter and have personal knowledge of the facts stated herein.
- Statement 2: My work schedule has permanently changed. I now work from 9:00 AM to 5:00 PM, Monday through Friday, which allows me to be available for our child every evening and weekend.
- Statement 3: Our child, Emily, is now 12 years old and has expressed a strong desire to spend more time at my residence and participate in extracurricular activities near my home.
- Place of Execution: Los Angeles, California
- Date of Execution: July 15, 2026
- Signature: Jane A. Smith
What this filled form sample shows:
- Correctly filled case caption with court, party names, and case number.
- Indicates self-representation by stating 'In Pro Per' in the attorney field.
- Provides clear, numbered factual statements to support a legal request.
- Properly completed execution section, signed under penalty of perjury with a current date and location.