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Uniform Child Custody Jurisdiction And Enforcement Act (UCCJEA) Affidavit Form. This is a Kansas form and can be use in District Court Statewide.
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Tags: Uniform Child Custody Jurisdiction And Enforcement Act (UCCJEA) Affidavit, Kansas Statewide, District Court
IN THE DISTRICT COURT OF ______________ COUNTY, KANSAS
____________________, Plaintiff
vs.
Case No. _______________
____________________, Defendant
UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
AFFIDAVIT
(K.S.A. 60-3101 et seq.)
I, (full legal name)
that the following statements are true:
, of lawful age, being first duly sworn, certify
1. The names and dates of birth of the children now under eighteen years of age and subject to
this proceeding are:
a._____________________________ (child’s name), was born in _________ (month) _________ (year).
b._____________________________ (child’s name), was born in _________ (month) _________ (year).
c._____________________________ (child’s name), was born in _________ (month) _________ (year).
d._____________________________ (child’s name), was born in _________ (month) _________ (year).
2. The child(ren) now live with:_______________________________________ (name of adult)
at _____________________________________________________________________ (Street address),
________________________________________ (city), ______________ (state) and have lived at this
place since ___________________________ (date).
*If you are the petitioner and have requested that the court keep your address confidential
pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you
to enter the address where you are currently living.
3. All the children lived together at the following addresses with the adults listed during the past
five years. If the children lived at different addresses from each other, complete this information for each
child separately using the spaces provided on page four. Make additional copies of page four as needed.
Name and Relationship of Adult(s)
From Date
Until Date
City, State
Living with Child, and Adult(s)
Present Address
12/3/10
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*If you are the petitioner and have requested that the court keep your address confidential
pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you
to enter the address where you are currently living.
4. I have have not been involved in a court case involving the custody or visitation of the
child(ren). The following court cases are on file about the child(ren):
Type of Case
Court, City and State
Case Number
Last Order Date
have
do not have information concerning ANY OTHER proceeding that could affect
5. I
the current proceeding, including but not limited to proceedings for enforcement and proceedings relating
to domestic violence, protective orders, termination of parental rights and adoption. The following court
cases are on file and could affect the current proceedings:
Type of Case
12/3/10
Court, City and State
Case Number
Last Order Date
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6. The following named persons not a party to this proceeding have physical custody or claim to
None
have custody or visitation rights with respect to any child subject to this proceeding:
Name
Address, City and State
Check the box that applies
Has Physical Custody
Claims Custody Rights
Claims Visitation Rights
Has Physical Custody
Claims Custody Rights
Claims Visitation Rights
Has Physical Custody
Claims Custody Rights
Claims Visitation Rights
Has Physical Custody
Claims Custody Rights
Claims Visitation Rights
Has Physical Custody
Claims Custody Rights
Claims Visitation Rights
7. I acknowledge that I have a continuing duty to inform the court of proceeding(s) in this or any
other state that could affect the current proceeding.
VERIFICATION
STATE OF ____________________ )
) ss:
COUNTY OF __________________ )
I swear or affirm that the statements made in this affidavit are true and correct to the best of
my knowledge and belief and that I am the person filing this affidavit.
__________________________________________
Plaintiff’s Signature
SUBSCRIBED AND SWORN to before me, a Notary Public, this ______ day of
_______________________________ 20
.
__________________________________________
Notary Public
My Appointment Expires:
___________________
12/3/10
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(Make as many copies of this page as necessary.)
THE FOLLOWING INFORMATION IS TRUE:
(Child’s Full Legal Name)
address(es) with the adult(s) listed during the past five years:
From Date
Until Date
City, State
, lived at the following
Name and Relationship of Adult(s)
Living with Child, and Adult(s)
Present Address
*If you are the petitioner and have requested that the court keep your address confidential
pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you
to enter the address where you are currently living.
THE FOLLOWING INFORMATION IS TRUE:
(Child’s Full Legal Name)
address(es) with the adult(s) listed during the past five years:
From Date
Until Date
City, State
, lived at the following
Name and Relationship of Adult(s)
Living with Child, and Adult(s)
Present Address
*If you are the petitioner and have requested that the court keep your address confidential
pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you
to enter the address where you are currently living.
12/3/10
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