1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 CC13 DISTRICT COURT CLARK COUNTY, NEVADA Plaintiff(s), -vs- CASE NO. DEPT. NO. Defendant(s). DECLARATION UNDER UNIFORM CHILD CUSTODY JURISDICTION ACT (NRS 125A.385) 1. There is/are child(ren) of the parties subject to this proceeding. The name, place of birth, birth date and sex of each child, the present address, periods of residence and places where each child has lived within the last five (5) years, and the name(s), present address and relationship to the child of each person with whom the child has lived during that time are listed in the table on the following page: ... 24 ... 25 ... 26 ... 27 ... 28 Declaration_UCCJ/10/22/2013 American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Child's Name A. Period of Residence to present to to Child's Name B. Period of Residence to present to to Child's Name C. Period of Residence to present to to Child's Name D. Period of Residence to present to to Child's Name E. Period of Residence to present to to Place of Birth Address Birth Date Person Child Lived With (Name & Current Address) Sex Relationship Place of Birth Address Birth Date Person Child Lived With (Name & Current Address) Sex Relationship Place of Birth Address Birth Date Person Child Lived With (Name & Current Address) Sex Relationship Place of Birth Address Birth Date Person Child Lived With (Name & Current Address) Sex Relationship Place of Birth Address Birth Date Person Child Lived With (Name & Current Address) Sex Relationship NOTE: Attach information about additional children or additional information on children listed above on attached sheet(s). Attached sheet(s) MUST be same size as this form. 2. I have have not (check one) participated as a party, witness, or in any other capacity in any other litigation or custody proceeding in this or any other state concerning custody of a child involved in this proceeding. 2 Declaration_UCCJ/10/22/2013 American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 If you checked "have" above, please supply the following information about the other proceeding(s): a. Name of each child involved: b. Your role in other proceeding(s): c. Court, state and case number of other proceeding(s): d. Date of court order or judgment in other proceeding(s): 3. I do do not (check one) know of any proceeding that could affect the current proceeding including proceedings for enforcement and proceedings related to domestic violence, protective orders, termination of parental rights and adoptions pending in a court of this or any other state concerning a child involved in this proceeding other than that set out in item 1 above. If you have checked do above, please supply the following information about the other proceeding(s): a. Name of each child involved: b. Your role in other proceeding(s): c. Court, state and case number of other proceeding(s): d. Date of court order or judgment in other proceeding(s): 4. I do do not (check one) know of any person not a party to this proceeding who has physical custody or claims to have custody or visitation rights with respect to any child subject to this proceeding. ... 3 Declaration_UCCJ/10/22/2013 American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 If you checked "do@ above, please supply the following information and check appropriate boxes below: a. Name and address of person(s): Person named has physical custody of (name of child) Person named claims custody rights as to (name of child) Person named claims visitation rights with (name of child) NOTE: Attach additional sheet(s) same size as this form if more room is needed for answers above. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. EXECUTED this day of , 20 . 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 __________________________________________ Tab to here, enter Name Tab to here, enter Address Tab to here, enter City/State/Zip Tab to here, enter Telephone 4 Declaration_UCCJ/10/22/2013 American LegalNet, Inc. www.FormsWorkFlow.com