THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT RSA 458-A It is important that you answer these questions with as much detail and accuracy as possible. Lack of adequate information could significantly delay orders being issued in your case. There are several situations that might result in New Hampshire exercising jurisdiction over child/ren. The continuous presence of the child/ren in New Hampshire for six (6) months is not the only basis for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a temporary basis. 1. List minor children born to or adopted by the parties: Name Date of Birth Current Address 2 List the places where the minor child/ren of the parties has/have lived in the last five (5) years and the names of the people they lived with at that time, if you know. Start with where the child lives now and work backward in time. Dates From/To Town/City, State Parent(s)/Caretaker Current Address/Contact Address of Parent/Caretaker Which Child/ren If more space is needed, attach Extra Page (Form NHJB-2656-FPS). I have attached Form NHJB-2656-FPS because additional space was needed. 3. Are there any person(s), not a party to this proceeding, who have physical custody of the child/ren or who claim to have custody, physical custody or parenting time rights? Yes No If yes, list name(s) and address(es) of person(s): NHJB-2660-DFPS (12/01/2010) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: UCCJEA AFFIDAVIT 4. Check one of the following: I have not participated in any court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. OR I have participated in court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following: Name of Court State Case No. Date of Court Order 5. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and responsibilities, termination of parental rights, adoption, juvenile, or other proceedings in any court in any state affecting any children named in this petition or parents of those children? Yes No If yes, complete the following: Name of Court State Case No. Type of Court Case 6. Optional: I am alleging, under oath, that my or my child/ren's health, safety, or liberty would be jeopardized by the disclosure of identifying information set forth in this Affidavit. To support my allegation, I state as follows: Note: In domestic violence actions under RSA 173-B, the whereabouts of the plaintiff shall not be released except by court order. I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child/ren in this case. I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Printed Name of Person Completing Affidavit Signature of Person Completing Affidavit State of This instrument was acknowledged before me on , County of by Date Person Signing Above My Commission Expires Affix Seal, if any NHJB-2660-DFPS (12/01/2010) Page 2 of 2 Signature of Notarial Officer / Title American LegalNet, Inc. www.FormsWorkFlow.com