IN THE COURT OF COMMON PLEAS DECLARATION UNDER UNIFORM CHILD CUSTODY Case No. ______________________ Division: Domestic Relations/Juvenile JURISDICTION AND ENFORCEMENT ACT (UCCJEA) 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 resting the court to not disclose my address or that of the child(ren). My address is confidential pursuant to ORC 3127.23(D) 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 Period of residence Place of birth Address Confidential Date of birth Person child lived with (name & address) Sex Relationship to Present to to to to b. Child's name Period of residence Place of birth Address Confidential Date of birth Person child lived with (name & address) Sex Relationship to Present to to to American LegalNet, Inc. www.USCourtForms.com d. Child's name Place of birth Date of birth Sex Residence information is the same as given above for child a. (If NOT the same, provide the information below.) Period of residence Address Confidential Person child lived with (name & address) Relationship to Present to to to Additional children are listed on Attachment 2e. (Provide requested information for additional children e. on an attachment.) Participation in custody proceeding(s): ( X only one) 3. ____ 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. b. c. d. 4. Name of each child ____________________________________________________________ Type of proceeding ____________________________________________________________ Court and state ____________________________________________________________ Date of court order or judgment (if any): ____________________________________________ Information about custody proceeding(s): ( X 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: ( X 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) American LegalNet, Inc. www.USCourtForms.com a. Name and address of person ____________________________________________________ ( ) claims custody rights ( ) claims visitation rights ( ) has physical custody Name of each child ______________________________________________________________ b. Name and address of person ____________________________________________________ ( ) claims visitation rights ( ) has physical custody ( ) claims custody rights Name of each child ______________________________________________________________ c. Name and address of person ____________________________________________________ ( ) has physical custody ( ) claims visitation rights ( ) claims custody rights Name of each child ______________________________________________________________ Knowledge of prior child support proceedings: (X only one) 6. ____ 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 ( X 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 imprisonment. and that the punishment for knowingly making a false statement includes fines and/or 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 ____Personally known ____Produced Identification Type of identification produced _________________________