STATE OF MAINE SUPERIOR COURT ________________________, ss. Docket No. _________________ DISTRICT COURT Location __________________ Docket No. ________________ ________________________Plaintiff v. AFFIDAVIT CONCERNING CHILD CUSTODY ________________________Defendant 1. This proceeding involves a request for the court to determine the custody of__________________ _______________________________________________________Date of Birth___________________ _______________________________________________________Date of Birth___________________ _______________________________________________________Date of Birth___________________ _______________________________________________________Date of Birth___________________ 2. The present address of said child(ren) is_______________________________________________ _____________________________________________________________________________________ 3. The following is a complete list of the places where said child(ren) have lived within the past five years, and the names and present address of all persons with whom said child(ren) have lived during that period: Dates of Residence Place (City and State) Person with whom child(ren) have lived Name Present Address 4. The undersigned has not participated as a party, witness or in any other capacity in other litigation concerning the custody of said child(ren), in this or any other State, except at follows:________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ THE UNDERSIGNED WILL ADVISE THE COURT OF ANY SUCH HEARING ARISING HEREAFTER. CV-051, Rev. 09/97 PAN 2000 © American LegalNet, Inc. There is no person, not a party to the present proceeding, what has physical custody of said child(ren), or claims to have custody or visiting rights with respect to said child(ren), except as follows:_______ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ The undersigned under oath and subject to the penalties of perjury, hereby declares that the statements made herein are true, upon the personal knowledge, information and belief of the undersigned, and so far as upon information and belief, that the undersigned believes them to be true. Signed___________________________________ Address___________________________________ ___________________________________ STATE OF MAINE _____________________County Personally appeared the above named ________________________________________________ and signed and made oath to the foregoing affidavit, before me, Date:_________________________ _______________________________________ Notary Public / Attorney at Law 2000 © American LegalNet, Inc.