STATE OF MAINE DISTRICT COURT Location ________________ Docket No. ______________ In re the Guardianship of: (Name of Minor) CHILD CUSTODY AFFIDAVIT IN SUPPORT OF APPOINTMENT OF GUARDIAN OF A MINOR 19-A M.R.S. § 1753 18-A M.R.S. § 5-204 I/We, ______________________________ and _______________________________________ am/are the petitioner(s) seeking to be appointed guardian(s) of the above-named child. The Petition for Guardianship / Temporary Guardianship we filed recites that the child's parents are:___________________________________________________________________________ ____________________________________________________________ The child's present address is: ______________________________________________________________________________ During the past five (5) years, the child has lived at the following addresses with the following people: Name of custodian Address of custodian when child was present Date of child's residence 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. GS-010, Rev. 10/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (C) know(s) of a person, not a party to this case, who has physical custody of the child or claims to have custody or visitation rights with respect to this child. (D) allege(s) that a living situation has been created that is at least temporarily intolerable for the minor and that we/I will provide a living situation that is in the best interest of the minor. If A, B, C, and/or D 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 foregoing statements are true. Before me, Date: ____________________________________ Attorney at Law/Notary Public/Deputy Clerk , and made oath that the *************************************************************************** COUNTY Personally appeared the above-named foregoing statements are true. Before me, Date: , and made oath that the ____________________________________ Attorney at Law/Notary Public/Deputy Clerk GS-010, Rev. 10/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com