CUSTODY AFFIDAVIT JD-JM-30 Rev. 10-12 P.B. 25-57; C.G.S. 52-231a P.A. 12-82, Sec. 16 CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Docket number Address of Court Name and address of child/youth Date of birth 1. Address(es) where the child has lived for the past five years: 2. Child lived with the following people during the past five years: 3. 4. There is not a proceeding in Connecticut or any other state now or in the past that could affect the custody of the child, or The following proceeding(s) affect the custody of the child: Nature of Proceedings Case Name Docket Number Court Location (Including state) Civil Criminal Juvenile Support Probate 5. The following person(s) has/have physical custody or claims to have custody or visitation rights with respect to the child. No one other than the petitioner/respondent Name and address: 6. The proceedings in this court on the pending matter concerning the child would not conflict with or interfere with any other pending proceeding. Has Has Not participated as a party or witness or in any other capacity, in 7. Any party to this action any other proceeding concerning the custody or or visitation with the child. I certify that the foregoing statements are true to the best of my knowledge and belief: Department of Children and Families by duly authorized representative: Signed (Duly authorized representative) Print or type name of person signing above Petitioner, if not agency: Signed (Subscriber) Print or type name of person signing above Subscribed and sworn to before me: On (Date) Signed (Notary Public, Assistant Clerk, Commissioner of Superior Court) ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. American LegalNet, Inc. www.FormsWorkFlow.com