STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE COUNTY OF MECKLENBURG DISTRICT COURT DIVISION CASE NUMBER ___________________ _____________________________ _____________________________ PLAINTIFF V S. AFFIDAVIT AS TO STATUS OF MINOR CHILD _____________________________ _____________________________ DEFENDANT .................................................................................................................................................................. _______________________________________ ____________________________________________ (Full name of affiant) (Present Street Address) __________________________________________________, being first duly sworn, deposes: (City) (State) (Zip) (Complete, striking inapplicable words, filling all blanks) 1. That said affiant is ___________________ of the minor (child) (children) who (is) (are) the subject of (Relationship) this action, and is the _______________________ in this action. (Plaintiff or Respondent) 2. That during the past five years, the (child) (children) have lived with: Name of Child __________________________ Birth Date ___________________ Birthplace ___________________________________ PERIOD ADDRESS PERSON LIVED WI TH PRESENT ADDRESS _______ to present ___________________ __________________________ __________________ ___________________ _______ to present ___________________ __________________________ __________________ ___________________ _______ to present ___________________ __________________________ __________________ ___________________ _______ to present ___________________ __________________________ __________________ ___________________ Form CCF- 29 August 2000 >>>> 2Name of Child __________________________ Birth Date ___________________ Birthplace ___________________________________ PERIOD ADDRESS PERSON LIVED WI TH PRESENT ADDRESS _______ to present ___________________ __________________________ __________________ ___________________ _______ to _______ ___________________ __________________________ __________________ ___________________ _______ to _______ ___________________ __________________________ __________________ ___________________ (If there are more than two children, insert additional sheets.) 3. That this affiant (has) (has not) participated as a (party) (witness) (other capacity) in litigation concerning the custody of the minor child in (this) (another) State, viz. ___________________________ _______________________________________ on __________________________, 20 ______. (If answer is affirmative, give details, stating capacity, name and address of court.) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4. That this affiant (has) (does not have) information of any custody proceeding concerning a child mentioned above pending in a Court of this or any other State. (If answer is affirmative, give details) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 5. That this affiant (knows) (does not know) of a person who has physical custody of the child, viz. ___________________________________________________, or claims to have custody or visitation rights with respect to the child, viz.: _______________________________________ ______________________________________ (Name) ( Address) This _________ day of __________________________ , 20_____ . ________________________________ A ffiant Sworn to and subscribed before me this _______ day of __________________ , 20_____ . ________________________________ Official authorized to administer oaths CCF-29 August 2000