Affidavit {308}

PROBATE COURT OF SHELBY COUNTY, OHIO IN THE MATTER OF THE PLACEMENT OF _________________________________ (Current Name of Child) CASE NO. ___________________________ AFFIDAVIT [R.C. 3127.23] State of Ohio, County of _____________________ s.s. Affiant being first duly sworn, deposes and says: 1. That the child's present address, the place(s) where the child has lived within the last five years, and the name and present address of each person with whom the child has lived during that period are: 2. That affiant has (not) participated as a party, witness, or in any other capacity in any proceeding concerning the allocation, between the parents of the same child, of parental rights and responsibilities for the care of the child including any designation of parenting time rights and the designation of the residential parent and legal custodian of the child or that otherwise concerned the custody of or visitation with the same child and, if so, the court, case number and the date of the child custody determination are attached. 3. That affiant has (no) information of any proceeding that could affect the current proceeding, including proceedings for enforcement of child custody determinations, proceedings relating to domestic violence or protection orders, proceedings to adjudicate the child as an abused, neglected, or dependent child, proceedings seeking termination of parental rights, and adoptions, and, if so, the court, the case number, and the nature of the proceeding are attached. 4. That affiant has (no) knowledge of any person who is not a party to the proceedings and has physical custody of the child or claims to be a parent of the child who is designated the residential parent and legal custodian of the child or to have parenting time rights with respect to the child or to be a person other than a parent of the child who has custody or visitation rights with respect to the child and, if so, the names and addresses of those persons are attached. 5. That affiant has (not) been previously convicted of or pleaded guilty to any criminal offense involving any act that resulted in a child being an abused child or a neglected child or previously been determined, in a case in which a child has been adjudicated an abused child or a neglected child, to be the perpetrator of the abusive or neglectful act that was the basis of the adjudication. If 2, 3, 4 or 5 is answered in the affirmative, and the space afforded is insufficient for full explanation, please attach and incorporate herein any necessary information. Affiant realizes that (s)he has a continuing duty to inform the Court of any parenting proceeding concerning the child in this or any other state of which affiant obtains information during the pendency of this proceeding. ________________________________________________ Signature of Affiant Sworn to before me and subscribed in my presence this ________day of __________________________, 20_____. ________________________________________________ Notary Public SCPC FORM 308 - AFFIDAVIT American LegalNet, Inc. www.FormsWorkFlow.com