STATE OF NORTH CAROLINA County Name And Address Of Plaintiff Court File No. In The General Court Of Justice District Court Division Name And Address Of Defendant VERSUS Name Of Minor Child Date Of Birth AFFIDAVIT AS TO STATUS OF MINOR CHILD G.S. 50A-209 Birthplace I, the undersigned affiant, being first duly sworn, say that during the past five (5) years the above named minor child has lived as follows: Period Of Residence From To Present Address Name Of Person Lived With Present Address Of Person I further say that: (Check those that apply) I have participated in litigation concerning the custody of the above named child. Capacity As Participant Date Of Child Custody Determination Details Case No. Name And Address Of Court I have information about a custody proceeding. Examples of custody proceeding include divorce, proceeding related to domestic violen ce, a protective order, termination of parental rights or adoption that is pending in a court of this or another state and could affect this proceeding. Name And Address Of Court Details I know of a person as listed below, who has physical custody or claims to have custody or visitation rights with respect to the above named child. Name And Address Of Person Physical Custody Claimed Custody Visitation Rights Date Signature Of Affiant Name Of Affiant (Type Or Print) SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Deputy CSC Notary Signature Of Person Authorized To Administer Oaths Assistant CSC Date Commission Expires County Where Notarized Clerk Of Superior Court Relationship To Above Named Child SEAL AOC-CV-609, Rev. 7/11 � 2011 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com