This document is not intended or offered as legal advice.

It has been prepared for educational and

informational purposes only. Please consult a legal professional if you have legal questions. Your
court may require different information or use different terminology.

[COUNTERCLAIM/COUNTERCOMPLAINT] TO
[PETITION/COMPLAINT] FOR [CASE TYPE]
[TYPE OF COURT] OF [STATE], COUNTY OF [NAME OF COUNTY]
Case number: [Enter case number]
PETITIONER/PLAINTIFF RESPONDENT/DEFENDANT
Name Name
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Date of Birth Date of Birth
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Street Address (including Apt) Street Address (including Apt)
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City/State/Zip Code City/State/Zip Code
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Attorney Name Attorney Name
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I, [your full name], state that:

1. I am filing a counterclaim to [type of document] filed against me.
2. I am the ☐ mother ☐ father ☐ [Specify other relation to child] of the following minor
child(ren):

Name(s) Date(s) of Birth

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3. The child(ren) live(s) at [address] with [name of person].

This document is not intended or offered as legal advice. It has been prepared for educational and
informational purposes only. Please consult a legal professional if you have legal questions. Your
court may require different information or use different terminology.

4. The child(ren) has/have lived in [state] for at least six (6) months ☐ yes ☐ no. In the past
five (5) years the child(ren) has/have lived in the following places with the following
person(s):

Time Period City and State Name(s) and Current

Address(es) of Person(s) with
whom Child(ren) Lived
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5. I know of the following cases, or I have been involved (as a party, witness, etc.) in the
following cases about me, the other party, or the child(ren). (e.g., custody, child support,
guardianship, domestic violence/protective order, paternity, divorce, visitation,
delinquency, termination of parental rights, adoption or other cases)

Court Case No. Type of Case Year Filed Result or Status (if
you know)
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to enter text. to enter text. to enter text. to enter text. enter text.
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to enter text. to enter text. to enter text. to enter text. enter text.
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to enter text. to enter text. to enter text. to enter text. enter text.

Attach the most recent court order for these cases.

6. I know of the following people, who are not parties in this case, who have physical
custody of or claim rights of legal custody, physical custody, or visitation with the
child(ren):

Name Current Address

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This document is not intended or offered as legal advice. It has been prepared for educational and
informational purposes only. Please consult a legal professional if you have legal questions. Your
court may require different information or use different terminology.

Click or tap here to enter text. Click or tap here to enter text.

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7. It is in the best interest of the child(ren) that I have (Check all that apply):
☐ joint legal custody ☐ sole legal custody of the child(ren) because
[State your main reasons briefly]
☐ joint physical custody ☐ sole physical custody of the child(ren) because
[State your main reasons briefly]
FOR THESE REASONS I want the court to (Check all that apply and attach forms indicated):
Grant me ☐ joint legal custody ☐ sole legal custody of the child(ren).
Grant me ☐ joint physical custody ☐ sole physical custody of the child(ren).

☐ Prohibit [name of person] from visiting with the child(ren) because [Explain briefly why the
other party should not have visits.]
☐ Allow [name of person] to visit with the child(ren) on the following terms.
If you selected joint physical custody or visitation, attach a proposed schedule or use the space
below to write one, including relevant holidays and school breaks:
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☐ Order [name of person(s)] to pay health insurance for child(ren).

☐ Order [name of person] to pay child support.

☐ Order: [Specify any other requests related to the child(ren). It’s usually easiest to explain
details by attaching a parenting plan.]

☐ Order any other appropriate relief.

I solemnly affirm under the penalties of perjury that the contents of this document are true to the
best of my knowledge, information, and belief.

________________________ ________________________
Signature Date
This document is not intended or offered as legal advice. It has been prepared for educational and
informational purposes only. Please consult a legal professional if you have legal questions. Your
court may require different information or use different terminology.

SWORN TO AND SUBSCRIBED before me this date:

_______________________
Notary Public