STATE OF NORTH CAROLINA COUNTY OF UNION __________________________, ) Plaintiff, ) VS ) ) __________________________, ) Defendant. ) IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION _____-CVD-__________ COMPLAINT FOR CHILD CUSTODY Plaintiff, complaining of defendant, alleges and says: PARTIES, JURISDICTION AND VENUE 1. Plaintiff is a citizen and resident of ______________________________________. (County and State) 2. Plaintiff's address is__________________________________________________. 3. Defendant is a citizen and resident of ____________________________________. (County and State) 4. Defendant's address is________________________________________________. 5. Defendant's relationship to child:________________________________________. (Mother, Father, etc.) 6. The name(s), age(s) and birth date(s) of the child or children at issue in this case is/are as follows: ___________________________________________________________________________ ___________________________________________________________________________ 7. Explain your standing to bring this civil action (e.g., I am the mother/father/other relative of the child/children): ___________________________________________________________________________ ___________________________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com 8. That during the past five years (or since birth if the child is less than five years old), the (child) (children) have lived with: Name of child _____________, birthdate _____________, birthplace _______________. PERIOD _____to present _____to _______ _____to _______ PERSON LIVED WITH _________________ _______________ _________________ _______________ ________________ _______________ ADDRESS PRESENT ADDRESS ___________________ ___________________ ___________________ Name of child _____________, birthdate _____________, birthplace _______________. PERSON LIVED PRESENT ADDRESS WITH ______to _____ _______________ ________________ ___________________ ______to _____ _______________ ________________ ___________________ ______to _____ _______________ ________________ ____________________ (If there are more than two children, insert additional sheets.) 9. That I (have) (have not) participated as a (party) (witness) (other capacity) in litigation concerning the custody/visitation of the minor child in (this) (another) State, viz._______________________________________________________________________on , (if answer is affirmative, give details, stating capacity, name and address of court.) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 10. That I (have) (do not have) information of any custody/visitation proceeding concerning a child mentioned above pending in a Court of this or any other State. (If answer is affirmative, give details)_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 11. That I (know) (do not know) of a person who has physical custody of the child . ______________________________________________________________, or (Name) (Address) claims to have custody or visitation rights with respect to the child, : __________________________________________________________________ (Name) (Address) 12. The District Court of Union County has personal jurisdiction over the parties and subject matter jurisdiction (including jurisdiction under the Uniform Child Custody Jurisdiction Act) to decide the claim(s) and render a custody determination in this action. 13. Venue of this action is properly in Union County, North Carolina. CUSTODY CLAIM PERIOD ADDRESS 6 American LegalNet, Inc. www.FormsWorkFlow.com 14. Plaintiff is a fit and proper person to have primary custody of the aforesaid minor child/children and an award of custody to her/him would best promote the interests and welfare of the aforesaid minor child/children. PRAYER FOR RELIEF WHEREFORE, plaintiff prays the Court for relief as follows: 1. 2. 3. That custody of the minor child/children be awarded to plaintiff. That defendant be taxed with the costs of this action. That plaintiff have and recover such other and further relief as the court may deem just and proper. This ____ day of ______________________, _____. ____________________________________________________________ (Signature of Plaintiff) ADDRESS AND TELEPHONE NUMBER OF PLAINTIFF: _____________________________________________ _____________________________________________ _____________________________________________ 7 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NORTH CAROLINA COUNTY OF UNION IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION ____CVD__________ VERIFICATION ______________________, being first duly sworn, deposes and says that he/she is the plaintiff in the foregoing action, that he/she has read the foregoing COMPLAINT and knows the contents thereof to be true of his/her own personal knowledge except for those matters and things alleged therein upon information and belief, and as to those matters and things, he/she believes same to be true. ____________________________________ (SIGN HERE) Sworn to and subscribed before me this ____ day of ________________, ______. ____________________________________ Notary Public ____________________________________ Printed name of notary My Commission expires________________ 8 American LegalNet, Inc. www.FormsWorkFlow.com