STATE OF MAINE _____________________COUNTY PROBATE COURT DOCKET NO. _______ JURISDICTIONAL AFFIDAVIT In Re ____________________________ Minor Child(ren) Pursuant to 4 M.R.S. � 251-A, in order to accept for filing a petition for paternity, guardianship of minor(s), a petition for termination of a guardianship of minor(s), a petition for adoption of minor child(ren), a petition to establish parental rights and responsibilities, a petition for termination of parental rights, or a petition for name change of minor child(ren), Maine's Probate Courts must first determine: 1) whether there are any pending cases involving the child or children in any of Maine's District Courts; and, 2) whether a case involving the child or children has ever been transferred from a Probate Court to a District 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 Probate Court in determining whether it has jurisdiction, you must provide the following information. 1. Name, date of birth, and address of minor child(ren) _________________________________ _____________________________________________________________________________ 2. Name, date of birth, address and telephone number of child(ren)'s first legal parent: ________ _____________________________________________________________________________ 3. Name, date of birth, address and telephone number of child(ren)'s second legal parent: ______ _____________________________________________________________________________ 4. Name, date of birth, address and telephone number of child(ren)'s guardian: _____________ ______________________________________________________________________________ 5. Name, date of birth, address and telephone number of PETITIONER: ___________________ _____________________________________________________________________________ 6. Relationship of petitioner to child(ren): ____________________________________________ 7. I, ______________, state under oath, that I know of no guardianship, adoption, name change, divorce, family matter, protection from abuse, protection from harassment, or child protective custody case concerning the child(ren) that is currently pending before any Maine District Court. 8. I, ______________, state under oath, that I know of no guardianship, adoption, or name change case concerning the child(ren) that is currently pending before any Maine Probate Court. 9. I, ______________, state under oath, that I know of no proceeding involving custody or other parental rights case concerning the child(ren) that is currently pending before any court of another state. American LegalNet, Inc. www.FormsWorkFlow.com 10. I, ______________, state under oath, that I know of no guardianship, adoption, or name change case concerning the child(ren) that was transferred from any Probate Court to the District Court. In order to determine whether there are any such pending or transferred cases, I have (check all that apply): Asked the the child(ren)'s first legal parent, who told me there is no case pending, and no case ever transferred. Asked the the child(ren)'s second legal parent, who told me there is no case pending, and no case ever transferred. Asked the the child(ren)'s guardian, who told me there is no case pending, and no case ever transferred. Checked with the clerk of the _______________ Probate Court, who told me there is no case concerning the child(ren) pending in that court, and no case ever transferred. Checked with the clerk of the ________________ District Court, who told me there is no case concerning the child(ren) pending in that court, and no case ever transferred. (Other) ______________________________________________________________ ________________________________________________________________________ 10. I, ______________, state under oath, that there is a judgment or order issued by the ____________________________ Court that currently affects the care and custody of the child(ren), but there is no open or pending case concerning the child(ren) in that court. A copy of that order is attached. 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. I understand that, if the Probate Court learns, at any time, that there is a case concerning the child(ren) pending in one of the Maine District Courts, the case initiated by this petition may be immediately transferred to that court. _____________________________________ ________________________________ 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: _________________________ American LegalNet, Inc. www.FormsWorkFlow.com