AFFIDAVIT CONCERNING CHILDREN JD-FM-164 Rev. 2-15 C.G.S. § 46b-115s P.B. § 25-57 Instructions www.jud.ct.gov Fill out this form completely. You must swear that your statements are true and sign this form in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit. At (Town) Probate District name and number Docket number STATE OF CONNECTICUT SUPERIOR COURT COURT OF PROBATE Court Use Only AFFACUS *AFFACUS* Judicial District of Plaintiff/Applicant's (Last, first, middle initial) Defendant/Respondent's (Last, first, middle initial) You must provide information about the past five years for each child affected by this case. Provide the information below. If you need more space, use form JD-FM-164A. Child's name (First, middle, last) Date of birth (Month, day, year) Date(s) of residence Place of residence (Town or city, and state, unless confidential by court order) Name(s) and present address(es) of person(s) child lived with (unless confidential) Relationship to child From (date) To The present From (date) To (date) From (date) To (date) From (date) To (date) From (date) To (date) Date of birth (Month, day, year) Child's name (First, middle, last) Residence information is same as for child above. (If not same, provide information) Relationship to child Date(s) of residence Place of residence (Town or city, and state, unless confidential by court order) Name(s) and present address(es) of person(s) child lived with (unless confidential) From (date) To The present From (date) To (date) From (date) To (date) From (date) To (date) From (date) To (date) Check here if additional children are listed on JD-FM-164A. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I have I have not been involved as a party or a witness or in any other capacity in a case 1. (Check one) or cases in Connecticut or in another state concerning custody of or visitation with any child listed in this affidavit. If you checked "I have," give the name of the court, the court case number and the date of the decision in the case or cases: (Check item 2 or 3 below) 2. I do not know of other civil or criminal cases in Connecticut or another state, now or in the past, that could affect the current case, including enforcement cases and family violence, protective order, termination of parental rights and adoption cases. I know of the following civil or criminal cases, in Connecticut or another state, now or in the past, that could affect the current case, including enforcement cases and family violence, protective order, termination of parental rights and adoption cases. Docket number Court location (Including state) 3. Case name Nature of proceeding Case name Docket number Court location (Including state) Nature of proceeding 4. (Check one) No one except the plaintiff/applicant and defendant/respondent has physical custody or claims to have custody or visitation rights regarding any child listed here. The following person(s) has physical custody or claims to have custody or visitation rights regarding any child listed here: Name: Address: (unless confidential) 5. The mother of the child(ren) named in the Complaint or Application is pregnant. Yes No Do not know 6. A child has been born to the mother named in the Complaint or Application after the filing of the Complaint or Application. Yes Child's name No Do not know If yes, fill in the following: Date of birth (Month, day, year) Signature Print name of person signing Sworn to before me (Assistant Clerk/Commissioner of Superior Court/Notary Public) Date signed JD-FM-164 Rev. 2-15 Page 2 of 2 You must tell the court about any case in Connecticut or another state that could affect this case, if you learn about it during this case. ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. American LegalNet, Inc. www.FormsWorkFlow.com