THIRD JUDICIAL DISTRICT COURT
COUNTY OF DONA ANA
STATE OF NEW MEXICO

                                                    )
                                                    )
                Petitioner,                    )
                                                    )        No. ________________
                                                    )
                vs.                                )        Judge ______________
                                                    )
                                                    )
                                                    )
                Respondent.                    )

    The undersigned hereby certifies that child custody/visitation issues

        [ ]    are

        [ ]    are not

involved in this matter.

    If such issues are involved, complete the following:

Minor Children Involved:

                Names                                                Date of Birth

_____________________________________            ______________

_____________________________________            ______________

_____________________________________            ______________

_____________________________________            ______________

    Issues Involved: (State type of issues involved (e.g., custody, visitation, etc.), and briefly describe position of each party in regard thereto.)

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

    DATED this ___ day of ___________, 19___.

                        _______________________________________
                        Attorney's or Party Pro Se Signature

                        _______________________________________
                        Name

                        _______________________________________
                        Address

                        _______________________________________

                        Telephone Number: ______________________