Custody Affidavit

IN THE COURT OF COMMON PLEAS OF FRANKLIN COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH Case No. ____________________ AFFIDAVIT/R.C. 3109.27 Judge ____________________ _________________________________________ __________________________________________ PLAINTIFF/PETITIONER SOCIAL SECURITY NUMBER ______________________________________________________________________________________ ADDRESS _________________________________________ __________________________________________ DEFENDANT/PETITIONER SOCIAL SECURITY NUMBER ______________________________________________________________________________________ ADDRESS _____________________ DATE OF MARRIAGE _________________FAMILY FILE NUMBER _________________________________, being first duly sworn, says that he/she is the plaintiff, defendant/petitioner in the cause hereinabove set forth, that the parties hereto are the natural/adoptive parents of the following named children: 1._______________________________ DOB_____________________ residing at ________________________ _________________________ 2._______________________________ DOB_____________________ residing at ________________________ _________________________ 3._______________________________ DOB_____________________ residing at ________________________ _________________________ 4._______________________________ DOB_____________________ residing at ________________________ _________________________ 5._______________________________ DOB_____________________ residing at ________________________ _________________________ 6._______________________________ DOB_____________________ residing at ________________________ _________________________ that said children resided for the five (5) preceding years at the address set forth below with names and parent addresses of persons with whom they resided: From_____________ to ____________________ With ____________________________________ At _______________________________________________________________________________ Current address _____________________________________________________________________ Custody affidavit (4-2002) Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2From_____________ to ____________________ With ____________________________________ At _______________________________________________________________________________ Current address _____________________________________________________________________ From_____________ to ____________________ With ____________________________________ At _______________________________________________________________________________ Current address _____________________________________________________________________ From_____________ to ____________________ With ____________________________________ At _______________________________________________________________________________ Current address _____________________________________________________________________ From_____________ to ____________________ With ____________________________________ At _______________________________________________________________________________ Current address _____________________________________________________________________ 1. Said Affiant (circle one) HAS/HAS NOT participed at as a party, witness or in any other capacity in any other litigation in this or any other state, that concerned the allocation, between the parents of the same child, of potential rights and responsibilities for the care of the child and the designation of the residential parent and legal custodian of the child or that otherwise concerned the custody ofth e same child. 2. Said affiant (circle one) HAS/DOES NOT HAVE information of any parenting proceeding concerning the child pending in the court of this or any other state. 3. Said affiant (circle one) KNOWS/DOES NOT KNOW of any person who is not a party to the proceeding and has physical custody of the choildr clai ms to be a parent of the child who is designated the residential parent and legal custodian of the child or to have visitation 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. 4. Said affiant previously (circle one)HAS/HAS NOT been 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 has been determined, in a case in which a child has been adjudicated an abused child or neglected child, to be the perpetrator of the abusive or neglectful act that was the basis of the adjudication. Said affiant has the following knowledge regarding irnmfoation set forth in paragraphs one through four above:______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Said affiant says that all the foregoing statements are true. ____________________________________ ____________________________________ Affiant A ttorney ____________________________________ ____________________________________ Notary Public Address Sworn to and subscribed by the affiant before me this ___________ day of _____________________, 20____. Custody affidavit (4-2002) Page 2 of 2