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Declaration Under Uniform Child Custody Jurisdiction And Enforcement Act Form. This is a Ohio form and can be use in Columbiana County (Court Of Common Pleas).
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Tags: Declaration Under Uniform Child Custody Jurisdiction And Enforcement Act, Ohio County (Court Of Common Pleas), Columbiana
IN THE COURT OF COMMON PLEAS
COLUMBIANA COUNTY, OHIO
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
Case No. _____________________
I, (full legal name)________________________________________, being sworn according to law, certify that
these proceedings involve the custody of a child, or children and the following statements are true:
1. [ ] I am requesting the court to not disclose my address or that of the child(ren). My address is confidential
pursuant to ORC 3127.23(0) and should be placed under seal in that the health, safety, or liberty of myself and/or the
child(ren) would be jeopardized by the disclosure of the identifying information.
2. (Number): ___________ Minor Child(ren) are subject to this proceeding as follows:
(Insert the information requested below. The residence information must be given for the last FIVE years.)
a. Child's name
Place of birth
Period of residence
To Present
Address
I Date of birth
Person child lived with (name & address)
Sex
Relationship
Confidential
to
to
to
to
a. Child's name
Place of birth
Period of residence
to Present
Address
-
Date of birth
Person child lived with (name & address)
Sex
Relationship
Confidential
to
to
to
to
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a. Child's name
Place of birth
Period of residence
to Present
Address
Date of birth
Person child lived with (name & address)
Sex
Relationship
Confidential
-
To
To
To
To
b. Additional children are listed on an attached addendum. (Provide all information for additional children
on an attachment.)
3. Participation in custody proceeding(s): (Check only one)
_____ I HAVE NOT participated as a party, witness, or in any capacity in any other litigation, in this or any
other state, concerning the custody of or visitation (parenting time) with any child subject to this proceeding.
_____ I HAVE participated as a party, witness, or in any capacity in any other litigation, in this or any other state,
concerning the custody of or visitation (parenting time) with any child subject to this proceeding. Explain:
a. Name of each child
b. Type of proceeding
c. Court and state
d. Date of court order or judgment (if any):
4.
Information about custody proceeding(s): (Check only one)
_____ I HAVE NO INFORMATION of any proceedings that could affect the current proceeding, including any
proceedings relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or
adoptions concerning any child subject to this proceeding.
______ I HAVE THE FOLLOWING INFORMATION concerning proceedings that could affect the current
proceeding, including any proceedings relating to custody, domestic violence or protection orders, dependency,
neglect or abuse allegations or adoptions concerning any child subject to this proceeding, other than set out in item
3. Explain:
a. Name of each child
b. Type of proceeding
c. Court and state
d. Date of court order or judgment (if any):
5. Persons not a party to this proceeding: (Check only one)
_____ I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or claims to
have custody or visitation rights with respect to any child subject to this proceeding.
_____ I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has/have physical
custody or claim(s) to have custody or visitation rights with respect to any child subject to this proceeding:
(See next page)
a. Name and address of person _____________________________________________________________
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(
) has physical custody
( ) claims custody rights
( ) claims visitation rights
Name of each child _______________________________________________________________________
b. Name and address of person _____________________________________________________________
( ) has physical custody
( ) claims custody rights
( ) claims visitation rights
Name of each child _______________________________________________________________________
c. Name and address of person _____________________________________________________________
(
) has physical custody
( ) claims custody rights
( ) claims visitation rights
Name of each child _______________________________________________________________________
6.
Knowledge of prior child support proceedings: (Check only one)
______ The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this or any state
or territory
______ The child(ren) described in this affidavit ARE subject to the following existing child support order(s):
a. Name of each child __________________________________________________________________________
b. Type of proceeding ___________________________________________________________________________
c. Court and address ____________________________________________________________________________
d. Date of court order or judgment (if any):___________________________________________________________
e. Amount of child support paid and by whom:________________________________________________________
7. I acknowledge that I have a continuing duty to advise this Court of any custody, visitation, child support,
or guardianship proceeding (including dissolution of marriage, child neglect, or dependency) concerning the
child(ren) in this state or any other state about which information is obtained during this proceeding.
I certify that a copy of this document was (Check only one) ( ) mailed ( ) faxed and mailed
( ) hand delivered to the person(s) listed below on (date ____________________________________)
Other party or his/her attorney:
Name:_____________________________________________Address:___________________________________
City, State, Zip:_______________________________________ Fax Number _____________________________
I understand that I am swearing or affirming under oath to the truthfulness of the statements made in this affidavit and
that the punishment for knowingly making a false statement includes fines and/or imprisonment.
Dated:___________________
____________________________________________________
Signature of Party
Printed name: _______________________________________
Address:____________________________________________
City, State, Zip: ______________________________________ Phone:_________________Fax:_______________
STATE OF OHIO
COUNTY OF _____________________________
Sworn to or affirmed and signed before me on_______________________by______________________________
____________________________________________
Notary Public
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