Preview
WARNING to Respondent: Without the advice and help of an attorney,you may be putting yourself and your
childrenat risk. For help finding an attorney,
call the State Bar of Texas Lawyer ReferralInformation Service at 1-
800-252-9690. If you or your childrenare a victim of familyviolence, or if atany time you feelunsafe, callthe
National Domestic Violence Hotline at 1-800-799-7233 or the Texas Family Violence Legal Line at 1-800-374-4673.
Cause Number: ;2...3 J - lo I lf 't 1~ -11
Fill in Cause number and court information exactly as it is written on the Petition.
In the Interest of the following Minor Child(ren): .
lnthe d-3,/
·s.r
(Print the full name of each child.)
Court Number
1 ~c,v,'j t~c.~c1!}j:ie- J,,-
2 0c, (i .I:.t,1.c;:z 1'~ [:fDistrict Court
3
O County Court at Law
4
otb/;,rc,,,,t:rcounty, Texas
5.
Waiver of Service Only (Specific Waiver)
INSTRUCTIONS to Respondent: ::::, ::;:_,
Talk to an attorney about your legal rights.If you decide to use this form: ~~ ~
• Fill it out completely.
You MUST include a mailing address and email address. '=:? c.n
:-, <:
• w
Do not sign it until at least one day after the Petition to Modify the Parent-Child Relationshi~it/iled
(turned in to the court). The official court stamp on your copy of the Petition will tell you whelHl;j_as fileo.
If
you sign this form before then, you will have to redo it. ;;:J-= :Z
• Sign it in front of a notary. Do not sign until you are standing in front of the notary. "'S2 ;;;:
• Give the original signed form back to the Petitioner or file it (turn it in to the court) whec,hePetition-
was filed. Keep a copy for your records.
• To finish this case by agreement, you, the Petitioner and any other Respondents named in the Petition
may complete and sign the Order Modifying the Parent-Child Relationship form. The Petitioner (or you)
may then take the agreed Order to Court for the Judge's signature.
• If you are not able to reach an agreement, the Petitioner must give you notice of any hearings in the case.
The person who signed this affidavit appeared, in person, before me, the undersigned
notary, and stated under oath:
"Iam the Respo\!Q.ent in this case. , . / ,f' ,
"My name is: Ua.v,cl
PRINT First
&re._ le
Middle .
1
Af:)f1.f(:'
Last
"My mailing address is:2
PRINT
s
gs;:o Mailing
slo.fe
Address
hu)<.[ 2~ ! I
r City
(,{Di/ld /Jl'c..!rie
State I
• I/, 7;;09-
Zip
"My email address is ck.vd,vc2Si c: l;t,I ( @C,;,,<,,"-fV.®vtA
"My phone number is: ( S17 l CJ/6 - S: 5 ~ C-,
"The last three numbers %-!)1Y driver's license number are: 3._ 9- 'o_. My driver's license
was issued in (State): _...L~"'"---------
Or "O I do not have a driver"s license number.
FM-Mod1-103 Waiver of Service Only (Specific Waiver) [Modification] (Rev. 09-2015) Page1of2
© TexasLawHelp.org
"The last three numbers of my social security number are:
Or "D I do not have a social security number.
}- Q_ q.
"I have been given a copy of the Petition to Modify the Parent-Child Relationship filed in this
case. I have read the Petition to Modify the Parent-Child Relationship and understand what it
says. I do not give up my right to review a different Petition to Modify the Parent-Child
Relationship if it gets changed (amended).
"I understand that I have the right to be given a copy of the Petition to Modify the Parent-Child
Relationship and official notice of this case by a constable, sheriff or other official process server
(legal notice). I give up my right to legal notice.
"Iask that the Court not enter any orders if they are not signed by me or if I have not received
prior written notice of the date, time and place of hearing.
"If I reach an agreement and sign an order in this case, the Court can enter the order without
giving me notice and without my being present. If I reach an agreement and sign an order in
this case, I do not want a court reporter to make a record of the testimony.
"I understand that I must give written notice to the Court, the Petitioner and any other
Respondents named in the Petition to Modify the Parent-Child Relationship if my mailing
address or email address changes during this case. I understand that if the Petitioner or
a Respondent is represented by an attorney I must give written notice to the attorney. If I
don't, then I understand that any notices about this case will be sent to me on the mailing
address or email address on this form.
Military Status
(Checy6nly one.)
"191 am not in the military."
"O I am in the military. I agree to the provisions stated above and I waive only the rights, privileges,
and exemptions I have under the Servicemembers Civil Relief Act that are contrary to those
provisions."
~
\, I
~ ~ - - - , ,
1gnature of Respondent (Do not sign until you are ,n
ront onotary.
1r(9/iz
Date
Notary fills out below.
State of fe
Preview
WARNING to Respondent: Without the advice and help of an attorney,you may be putting yourself and your childrenat risk. For help finding an attorney, call the State Bar of Texas Lawyer ReferralInformation Service at 1- 800-252-9690. If you or your childrenare a victim of familyviolence, or if atany time you feelunsafe, callthe National Domestic Violence Hotline at 1-800-799-7233 or the Texas Family Violence Legal Line at 1-800-374-4673. Cause Number: ;2...3 J - lo I lf 't 1~ -11 Fill in Cause number and court information exactly as it is written on the Petition. In the Interest of the following Minor Child(ren): . lnthe d-3,/ ·s.r (Print the full name of each child.) Court Number 1 ~c,v,'j t~c.~c1!}j:ie- J,,- 2 0c, (i .I:.t,1.c;:z 1'~ [:fDistrict Court 3 O County Court at Law 4 otb/;,rc,,,,t:rcounty, Texas 5. Waiver of Service Only (Specific Waiver) INSTRUCTIONS to Respondent: ::::, ::;:_, Talk to an attorney about your legal rights.If you decide to use this form: ~~ ~ • Fill it out completely. You MUST include a mailing address and email address. '=:? c.n :-, <: • w Do not sign it until at least one day after the Petition to Modify the Parent-Child Relationshi~it/iled (turned in to the court). The official court stamp on your copy of the Petition will tell you whelHl;j_as fileo. If you sign this form before then, you will have to redo it. ;;:J-= :Z • Sign it in front of a notary. Do not sign until you are standing in front of the notary. "'S2 ;;;: • Give the original signed form back to the Petitioner or file it (turn it in to the court) whec,hePetition- was filed. Keep a copy for your records. • To finish this case by agreement, you, the Petitioner and any other Respondents named in the Petition may complete and sign the Order Modifying the Parent-Child Relationship form. The Petitioner (or you) may then take the agreed Order to Court for the Judge's signature. • If you are not able to reach an agreement, the Petitioner must give you notice of any hearings in the case. The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated under oath: "Iam the Respo\!Q.ent in this case. , . / ,f' , "My name is: Ua.v,cl PRINT First &re._ le Middle . 1 Af:)f1.f(:' Last "My mailing address is:2 PRINT s gs;:o Mailing slo.fe Address hu)<.[ 2~ ! I r City (,{Di/ld /Jl'c..!rie State I • I/, 7;;09- Zip "My email address is ck.vd,vc2Si c: l;t,I ( @C,;,,<,,"-fV.®vtA "My phone number is: ( S17 l CJ/6 - S: 5 ~ C-, "The last three numbers %-!)1Y driver's license number are: 3._ 9- 'o_. My driver's license was issued in (State): _...L~"'"--------- Or "O I do not have a driver"s license number. FM-Mod1-103 Waiver of Service Only (Specific Waiver) [Modification] (Rev. 09-2015) Page1of2 © TexasLawHelp.org "The last three numbers of my social security number are: Or "D I do not have a social security number. }- Q_ q. "I have been given a copy of the Petition to Modify the Parent-Child Relationship filed in this case. I have read the Petition to Modify the Parent-Child Relationship and understand what it says. I do not give up my right to review a different Petition to Modify the Parent-Child Relationship if it gets changed (amended). "I understand that I have the right to be given a copy of the Petition to Modify the Parent-Child Relationship and official notice of this case by a constable, sheriff or other official process server (legal notice). I give up my right to legal notice. "Iask that the Court not enter any orders if they are not signed by me or if I have not received prior written notice of the date, time and place of hearing. "If I reach an agreement and sign an order in this case, the Court can enter the order without giving me notice and without my being present. If I reach an agreement and sign an order in this case, I do not want a court reporter to make a record of the testimony. "I understand that I must give written notice to the Court, the Petitioner and any other Respondents named in the Petition to Modify the Parent-Child Relationship if my mailing address or email address changes during this case. I understand that if the Petitioner or a Respondent is represented by an attorney I must give written notice to the attorney. If I don't, then I understand that any notices about this case will be sent to me on the mailing address or email address on this form. Military Status (Checy6nly one.) "191 am not in the military." "O I am in the military. I agree to the provisions stated above and I waive only the rights, privileges, and exemptions I have under the Servicemembers Civil Relief Act that are contrary to those provisions." ~ \, I ~ ~ - - - , , 1gnature of Respondent (Do not sign until you are ,n ront onotary. 1r(9/iz Date Notary fills out below. State of fe