IN THE COMMON PLEAS COURT OF LICKING COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS __________________________________________ Plaintiff/Petitioner (1) SS #_____________________ DOB ____________ Address ___________________________________ ___________________________________ V. : Case No____________________________ : CSEA No ___________________________ : : Family File No _______________________ __________________________________________ : JUDGE STEINER Defendant/Petitioner (2)/Respondent : SS #_____________________ DOB ____________ MAGISTRATE _______________________ Address ___________________________________ ___________________________________ Information For Parenting Proceeding (O.R.C. 3109.27) Notes: By law, this affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this court. Each party has a continuing duty while this case is pending to inform the court of any parenting proceeding concerning the child(ren) in any other court in this or any other state. If more space is needed, attach an additional page. Affiant ________________________________________ 1. The name, birth date, Social Security Number (if any) of each child whose custody/visitation is at issue in this case is: The present home address of the child(ren) is: states as follows: 2. 3. The child(ren) currently reside(s) with what adult(s)? All other places and dates where the child(ren)have lived during the last 6 years, and the names of all adult(s) with whom they lived at each address, are as follows: 4. Parenting Affidavit Page 1 of 2 5. The name(s) and current address of all adults listed above are: Do you know of any litigation anywhere, past or present, which concerns the American LegalNet, Inc. www.USCourtForms.com 6. custody, visitation, or care of the child(ren)? 7. If the answer to #6 is "yes", state any other information you have about any parenting proceeding concerning the child(ren) now pending in a court of this or any other state. Including the case number, the name of the court and the address of the court. State the name and address of any person who is not a part to this proceeding: (A) who has physical possession of the child(ren) or (B) who claims to be a parent of the child(ren) and is either the residential parent and legal custodian, or has visitation rights with the child, or (C) who is a person other than a parent of the child(ren) who has custody or visitation rights. Are you now, or have you ever been, a party to any civil or criminal case or any investigation concerning child abuse, child neglect, or domestic violence? If so, state each court, case name, case number, date and nature and outcome of the case: Do you have any domestic violence protection orders or any other restraining orders issued against you, or on your behalf against any other person? If so, state each court, case name, case number, date and nature and outcome of the case: 8. 9. 10. OATH OF AFFIANT I hereby swear or affirm that the answers above are true, complete and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.11). ______________________________________________ AFFIANT Sworn to and subscribed before me on this ___________ day of ____________________, ________ ______________________________________________ Notary Public Parenting Affidavit Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com