STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CHILD CUSTODY AFFIDAVIT 19-A M.R.S. � 1753 I/We, ______________________________ and ______________________________ am/are the petitioner(s) seeking to adopt the above-named child. The Petition for Adoption we filed recites that the child's parents are: _____________________ ______________________________________________________________________________ The child's present address is: ______________________________________________________________________________ During the past five years, the child has lived at the following addresses with the following people: Address of custodian when Date of child's residence child was present with this custodian ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The custodian(s) named above currently live at the following address(es): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ We, or one of us (check as many as are true): (A) have/has participated as a party, witness, or in some other capacity in other litigation concerning the custody of this child in Maine or another state. (B) have/has information of a custody proceeding concerning this child pending in a court in Maine or some other state. (C) know(s) of a person, not a party to this case, who has physical custody of the child Name of custodian AD-005, Rev. 07/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com or claims to have custody or visitation rights with respect to this child. If A, B, or C has been checked, additional information concerning that issue is attached to this affidavit. Dated: Petitioner Dated: Petitioner STATE OF MAINE COUNTY Personally appeared the above-named that the foregoing statements are true. Before me, Date: , and made oath ____________________________________ Attorney at Law/Notary Public/Deputy Clerk *************************************************************************** COUNTY Personally appeared the above-named that the foregoing statements are true. Before me, Date: , and made oath ____________________________________ Attorney at Law/Notary Public/Deputy Clerk AD-005, Rev. 07/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com