State of Alabama Unified Judicial System Page 1 of 2 JU-23 CHILD CUSTODY PROCEEDING AFFIDAVIT 1/09 Case Number (Ala. Code 1975, §30-3B-209) IN THE __________________________ COURT OF __________________ COUNTY, ALABAMA (Circuit, District or Probate) (Name of County) [Check one of the following boxes]: [ ] In the matter of ______________________________________________________, a child [ ] In the matter of the Adoption Petition of [Full Name(s) and Age(s) of Petitioner(s) and His/Her/Their Residence Address(es), Including City(ies) or Town(s), State(s), and Zip Code(s)]: __________________________________________________________________________________ __________________________________________________________________________________ [ ] ________________________________ v. ________________________________________ Plaintiff Defendant Before me, the undersigned authority, personally appeared _______________________________ (Name of Affiant), who first by me being duly sworn, on oath, provides the following: Child’s present address or whereabouts: __________________________________________ ______________________________________________________________________________ Place(s) where the child has lived in the past five years: _____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Name(s) and present address(es) of the person(s) with whom the child has lived in the past 5 years: Name:_____________________________ Address:___________________________ __________________________________ Name:_____________________________ Address:___________________________ __________________________________ Name:_____________________________ Address:___________________________ __________________________________ Name:_____________________________ Address:___________________________ __________________________________ [ ] I have participated as a party or witness in the following custody or visitation proceeding(s) concerning this child. [Check whether you were a party or witness, the court in which the case was filed, the case number, and the date of the custody determination]: [ Party [ Witness [ ] Party [ ] Witness Name of Court: ______________________ Name of Court: ______________________ Case Number: ______________________ Case Number: ______________________ Date of Custody Det.: _________________ Date of Custody Det.: _________________ [ Party [ ] Witness [ ] Party [ ] Witness Name of Court:______________________ Name of Court:______________________ Case Number: ______________________ Case Number: ______________________ Date of Custody Det.: _________________ Date of Custody Det.: _________________ Ala.Code 1975, §12-15-121(a) American LegalNet, Inc. www.FormsWorkFlow.com State of Alabama Unified Judicial System Page 2 of 2 JU-23 1/09 CHILD CUSTODY PROCEEDING AFFIDAVIT Case Number (Ala. Code 1975, §30-3B-209) [ I have knowledge of the following proceedings (including proceedings relating to domestic violence, protection from abuse, termination of parental rights, and adoption) that may affect the current case: Type of Case: _______________________ Court: _____________________________ Case Number: ______________________ Type of Case : ________________________ Court: ______________________________ Case Number: ________________________ Type of Case: _______________________ Court: _____________________________ Case Number: ______________________ Type of Case : ________________________ Court: ______________________________ Case Number: ________________________ [ I have knowledge of the following person(s) who have physical custody of the child other than the parties: Name:_____________________________ Address:___________________________ __________________________________ Name:_____________________________ Address:___________________________ __________________________________ __________________________________ Affiant Sworn to and subscribed before me on this the ________ day of ______________, ________. ______________________________________ Judge/Clerk/Magistrate Ala. Code 1975, §12-15-121(a) American LegalNet, Inc. www.FormsWorkFlow.com