STATE OF MAINE DISTRICT COURT Location Docket No. In re: ________________________ Minor Child(ren) JURISDICTIONAL AFFIDAVIT 4 M.R.S. � 152(5-A) Pursuant to 4 M.R.S. � 152(5-A), in order for the District Court to accept for filing a petition for guardianship, adoption or name change concerning a minor child or children, there must already be a pending case in the District Court concerning custody or other parental rights concerning that child or children, OR a case involving the children must have already been transferred from a Probate Court. A "pending" case is a case that has been filed in a District Court, is being litigated in that court, and/or is awaiting decision by that court. In order to assist the District Court in determining whether it has jurisdiction, you must provide the following information. Petitioner's(s') name(s), date(s) of birth, and address(es): _________________________________________________________________________________ ___________ __________________ 1. Petitioner(s) wish/es to file a guardianship, adoption or name change case involving the following child(ren) (provide name, date of birth, and address of minor child(ren)): ________________________________________________________________________________ ________________________________________________________________________________ Petitioner(s) claim/s that the District Court has jurisdiction over this case because (CHECK ALL THAT ARE TRUE): A. There is a case concerning the child(ren) that is currently pending before a Maine District Court. The case name is _______________________________________, docket number _________________________, and it is pending in the ____________________ District Court. B. There is a second case concerning the child(ren) that is currently pending before a Maine District Court. The case name is _______________________________________, docket number ____________________, and it is pending in the ____________________ District Court. C. Although there is no pending case in the District Court, a guardianship, adoption, or name change case concerning the child(ren) was transferred from a Probate Court to the District Court. The name of that case is __________________________________, its docket number is ______________, and it was transferred from __________________ Probate Court to the PB-003, Rev. 10/16 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com ____________________ District Court. 2. (CHOOSE ONE) There is / is not a guardianship, adoption, or name change case concerning the child(ren) that is currently pending before any Maine Probate Court. 3. (CHOOSE ONE) There is / is not a judgment or order issued by the ________________________ Court that currently affects the care and custody of the child(ren). A copy of that order is attached. 4. Name, date of birth, address and telephone number of child(ren)'s first legal parent: ___________ ________________________________________________________________________________ 5. Name, date of birth, address and telephone number of child(ren)'s second legal parent: ________ ________________________________________________________________________________ 6. Name, date of birth, address and telephone number of child(ren)'s guardian: _________________ ________________________________________________________________________________ 7. Telephone number of PETITIONER(S): ______________________________________________ 8. Relationship of petitioner(s) to child(ren): ___________________________________________ I understand that, if I give false information on this form, I may be subject to a determination that I am in contempt of court, and I may be sanctioned for that contempt. _____________________________________ Petitioner Signature ______________________________________ Date STATE OF MAINE COUNTY OF _________________ ____________________________ personally appeared and made oath that the foregoing is true to the best of his/her knowledge, information and belief and, to the extent it is based upon his/her information and belief, that s/he believes the same to be true. Dated: _______________________________ Notary Public: ______________________________ _____________________________________ Petitioner Signature PB-003, Rev. 10/16 ______________________________________ Date Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MAINE COUNTY OF _________________ ____________________________ personally appeared and made oath that the foregoing is true to the best of his/her knowledge, information and belief and, to the extent it is based upon his/her information and belief, that s/he believes the same to be true. Dated: _______________________________ Notary Public: ______________________________ PB-003, Rev. 10/16 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com