DR-804 Rev. COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO CASE NUMBER: Plaintiff/Petitioner s SUPPLEMENTAL AFFIDAVIT Defendant/Petitioner 1.I, , am the parent of the following minor child/ren: Name Date of Birth: Name Date of Birth: Name Date of Birth: Name Date of Birth: 2.The present address of my former spouse (the non-residential parent) is: 3. a) has has not been convicted of or pleaded guilty to a violation of Ohio Revised Code Section2919.25 (criminal domestic violence)involving a victim who, at the time of the commission of the offense,was a member of the family or household that is the subject of the proceedings in this case. b) has has not been convicted of or pleaded guilty to any other offense which caused harm to avictim who, at the time of the offense, was a member of the family or household that is the subject of theproceedings in this case; c) has has not been determined to be the person who committed an act which is the basis of acourt finding that a child has been abused. Sworn to and subscribed before me this day of , 20 . Notary Public My commission expires NOTE: This affidavit is only required if you are requesting that your new address be withheld from the former spouse. If the response to each of the statements in question #3 is 223has not224, the Court will issue an order stating that the non-residential parent is to be sent a copy of this any subsequent Notice of Intent to Relocate that is filed with the Court. If the response to any of the statements in question #3 is 223has,224 the Court will issue an order stating that the non-residential parent not be sent a copy of this or any future Notice of Intent to Relocate. The Court will, however, send a notice to the non-residential parent that he/she may file a motion request a court hearing to determine whether it would be in the best interest of the child/ren that he/she be given the new address, and whether the parenting time order should be revisited. American LegalNet, Inc. www.FormsWorkFlow.com