Form 346 Rev. (12/2017) 1 of 3 The Family Court of the State of Delaware In and For New Castle Kent Sussex County CUSTODY SEPARATE STATEMENT Petitioner v. Respondent Name Name File Number 1. What type of petition are you filing? 2. Who is the child(ren) named in your petition? (Please provide full name and date of birth) Child222s Name Date of Birth (mm/dd/yyyy) Place of Birth (City, State) 3. Have all the children listed above continually resided with one another? Yes No If you answered 223No,224 the children have not continually resided with one another; please complete a Custody Separate Statement for each child. CURRENT ADDRESS Address where child(ren) currently reside(s) ** If the address where the child(ren) currently resides is a confidential address in Family Court, DO NOT provide the address on this form. Instead, please mark the fields as CONFIDENTIAL. Date(s) Child(ren) lived here to present Address City State Zip People living in the household with the child(ren): Date of Birth Relationship to child(ren): 4. During the past five years, where has/have the child(ren) lived? List addresses from the most recent to the oldest. If the child(ren) is under the age of five years old, end with the first address where the child lived. PRIOR ADDRESS Address where child(ren) previously resided City State Zip Code Date(s) child(ren) lived there Name of person(s) child(ren) lived with Relationship to child(ren) t o Person222s current address City State Zip Code PRIOR ADDRESS Address where child(ren) previously resided City State Zip Code Date(s) child(ren) lived there Name of person(s) child(ren) lived with Relationship to child(ren) t o Person222s current address City State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com Form 346 Rev. (12/2017) 2 of 3 PRIOR ADDRESS Address where child(ren) previously resided City State Zip Code Date(s) child(ren) lived there Name of person(s) child(ren) lived with Relationship to child(ren) t o Person222s current address City State Zip Code PRIOR ADDRESS Address where child(ren) previously resided City State Zip Code Date(s) child(ren) lived there Name of person(s) child(ren) lived with Relationship to child(ren) t o Person222s current address City State Zip Code 5. Check ONE and complete as directed. No one other than the parties have physical custody, legal custody or visitation rights with the child(ren). A person(s) other than the parties have physical custody, legal custody or visitation rights with the child(ren). If you check this box, complete the information below. Attach additional sheets if necessary. PERSON 1 Name of person(s) with physical custody, legal custody or visitation Relationship to child(ren) Person222s current address City State Zip Code PERSON 2 Name of person(s) with physical custody, legal custody or visitation Relationship to child(ren) Person222s current address City State Zip Code 6. Select all that apply and complete as directed. I have not been involved in any other court action for custody and/or visitation of this child(ren). I have been involved in another court action for custody and/or visitation of this child(ren). If you check this box, complete the information below. Attach additional sheets if necessary. ACTION 1 Type of Action (e.g. Custody, Visitation, Other) Person (who filed the action) State Court Case Number Date Filed Result Date of Order ACTION 2 Type of Action (e.g. Custody, Visitation, Other) Person (who filed the action) State Court Case Number Date Filed Result Date of Order ACTION 3 Type of Action (e.g. Custody, Visitation, Other) Person (who filed the action) State Court Case Number Date Filed Result Date of Order American LegalNet, Inc. www.FormsWorkFlow.com Form 346 Rev. (12/2017) 3 of 3 7. Check ONE and complete as directed. I do not know of any other court action such as, Protection From Abuse, Termination of Parental Rights, Guardianship, Adoption or Paternity involving myself, the other party or the child(ren) that could affect this petition. I, the other party or the child(ren) have been and/or are currently involved in another court action such as, Protection From Abuse, Termination of Parental Rights, Guardianship or Adoption, that could affect this petition. If you check this box, complete the information below. Attach additional sheets if necessary. ACTION 1 Type of Action (e.g. PFA, TPR, Guardianship, Other) Person (who filed the action) State Court Case Number Date Filed ACTION 2 Type of Action(e.g. PFA, TPR, Guardianship, Other) Person (who filed the action) State Court Case Number Date Filed Petitioner Sworn to and subscribed before me this day of , . Clerk of Court/Notary Public American LegalNet, Inc. www.FormsWorkFlow.com