Information For Parenting {4}

Court Form 4 Eff. 7/1/07 IN THE COM M ON PLEAS COURT OF HURON COUNTY, OHIO DIVISION OF DOM ESTIC RELATIONS _____________________________________________ Petitioner : Case No. ______________________________________ : : v. : _____________________________________________ Respondent : INFORM ATION FOR PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A)) Judge James W . Conway NOTE: By law, an affidavit must be filed an served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court, including a Petition for a Domestic Violence Civil Protection Order. Each party has a continuing duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other court in this or any other state. If more space is needed, attach an additional page. I (full legal name) ______________________________________________, being sworn according to law, certify these cases involve the custody of a child or children and the following statements are true: 1. G I am requesting the court to not disclose my current address or that of the child(ren). My address is confidential pursuant to R.C. 3127.23(D) and should be placed under seal in that the health, safety, or liberty of myself and/or the child(ren) would be jeopardized by the disclosure of the identifying information. 2. (Number): __________ M inor Child(ren) are subject to this case as follows: (Insert the information requested below. The residence information must be given for the last FIVE years.) a. Child's name Period of residence Place of birth GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential Date of birth Sex Relationship Person child lived with (name & address) _______ to present _______ to ______ _______ to ______ _______ to ______ b. Child's name Period of residence Place of birth GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential Date of birth Sex Relationship Person child lived with (name & address) _______ to present _______ to ______ _______ to ______ _______ to ______ American LegalNet, Inc. www.FormsWorkFlow.com c. Child's name Period of residence Place of birth GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential Date of birth Sex Relationship Person child lived with (name & address) _______ to present _______ to ______ _______ to ______ _______ to ______ d. Child's name Period of residence Place of birth GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential GAddress Confidential Date of birth Sex Relationship Person child lived with (name & address) _______ to present _______ to ______ _______ to ______ _______ to ______ e. Additional children are listed on Attachment 2(d). (Provide requested information for additional children on an attachment labeled 2d.) 3. Participation in custody case(s): (only one) G I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitiaion (parenting time) with any child subject to this case. G a. b. c. d. 4. I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitation (parenting time) with any child subject to this case. Explain: Name of each child _________________________________________________________________ Type of case __________________________________________________________________ Court and State __________________________________________________________________ Date and court order or judgement (if any): ______________________________________________________ Information about custody case(s): (only one) G I HAVE NO INFORM ATION of any cases that could affect the current case, any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case. G a. b. c. d. I HAVE THE FOLLOWING INFORM ATION concerning cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case, other than listed in Paragraph 3. Explain: Name of each child _________________________________________________________________ Type of case _________________________________________________________________ Court and State _________________________________________________________________ Date and court order or judgement (if any): ______________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 5. List all of the criminal convictions including guilty pleas for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm tot he victim during the commission of the offense. CASE NUM BER COURT/STATE/COUNTY CHARGE NAM E 6. Persons not a party to this case: (only one) G I DO NOT KNOW OF ANY PERSON not a party to this case who has physical custody or claims to have custody or visitation rights with respect to any child subject to this case. G I KNOW THAT THE FOLLOW ING N AM ED PERSON(S) not a party to this case has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this case: Name and address of person __________________________________________________________________ a. G has physical custody Name of each child G claims custody rights G claims visitation rights __________________________________________________________________________ __________________________________________________________________ b. Name and address of person G has physical custody Name of each child G claims custody rights G claims visitation rights __________________________________________________________________________ __________________________________________________________________ c. Name and address of person G has physical custody Name of each child G claims custody rights G claims visitation rights ______________________________