DR616 Rev. 5/07 IN THE COURT OF COMMON PLEAS, DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO _______________________________ Petitioner : Case No._______________________________ : Judge _________________________________ : v. : _______________________________ Respondent INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A)) : NOTE: By law, this affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/parenting time) proceeding in this Court, including a Petition for a Domestic Violence Civil Protection Order. Each party has a continuing duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other court in this or any other state. If more space is needed, attach an additional page. I (full legal name) ________________________, being sworn according to law, certify these cases involve the custody of a child or children and the following statements are true: 1. □ I am requesting the court to not disclose my current address or that of the child(ren). My address is confidential pursuant to R.C. 3127.23(D) and should be placed under seal in that the health, safety, or liberty of myself and/or the child(ren) would be jeopardized by the disclosure of the identifying information. 2. _____ Minor Child(ren) are subject to this case as follows: (Insert the information requested below. The residence information must be given for the last FIVE years.) a. Child’s Name: Period of Residence Place of birth: □ Address Confidential _______ to Present □ Address Confidential _______ to _______ □ Address Confidential _______ to _______ Relationship □ Address Confidential _______ to _______ Person child lived with (name and address) Sex: □ Address Confidential _______ to _______ Date of birth: □ Address Confidential American LegalNet, Inc. www.FormsWorkflow.com b. Child’s Name: Period of Residence Place of birth: □ Address Confidential _______ to Present □ Address Confidential _______ to _______ □ Address Confidential c. Child’s Name: Place of birth: Relationship □ Address Confidential _______ to _______ Person child lived with (name and address) □ Address Confidential _______ to _______ Sex: □ Address Confidential _______ to _______ Date of birth: Period of Residence □ Address Confidential _______ to Present □ Address Confidential _______ to _______ □ Address Confidential _______ to _______ Relationship □ Address Confidential _______ to _______ Person child lived with (name and address) Sex: □ Address Confidential _______ to _______ Date of birth: □ Address Confidential d. Additional children are listed on Attachment. Provide requested information for additional children on attachment page. American LegalNet, Inc. www.FormsWorkflow.com 3. Participation in custody case(s): (only one) □ I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or parenting time with any child subject to this case. □ I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody or parenting time with any child subject to this case. EXPLAIN: a. Name of each child: _____________________________________________________________________ b. Type of case: _____________________________________________________________________ c. _____________________________________________________________________ Court and State: d. Date and court order or judgment (if any): ________________________________________________________ 4. Information about custody case(s): (only one) □ I HAVE NO INFORMATION of any cases that could affect the current case, any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case. □ I HAVE THE FOLLOWING INFORMATION concerning cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case, other than listed in Paragraph 3. EXPLAIN: e. Name of each child: _____________________________________________________________________ f. Type of case: _____________________________________________________________________ g. Court and State: _____________________________________________________________________ h. Date and court order or judgment (if any): ________________________________________________________ 5. List all criminal convictions including guilty pleas for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm to the victim during the commission of the offense. NAME CASE NUMBER COURT/STATE/COUNTY CHARGE American LegalNet, Inc. www.FormsWorkflow.com 6. Persons not a party to this case: (only one): □ I DO NOT KNOW OF ANY PERSON not a party to this case who has physical custody or claims to have custody or parenting rights with respect to any child subject to this case. □ I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical custody or claims to have custody or parenting rights with respect to any child subject to this case: a. Name and address of person: _____________________________________________________ □ has physical custody □ claims custody rights □ claims parenting time b. Name and address of person: _____________________________________________________ □ has physical custody c. □ claims parenting time Name and address of person: _____________________________________________________ □ has physical custody 7. □ claims custody rights □ claims custody rights □ claims parenting time I understand that I have a continuing duty to advise this Court of any custody, parenting time, divorce, dissolution of marriage, separation, neglect, abuse, dependency, guardianship, parentage, termination of parental rights, or protection from domestic violence case concerning the child(ren) in this state or any other state about which information is obtained during this case. OATH OF AFFIANT I hereby swear or affirm that the answers above are true, complete and accurate to the best of my knowledge. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.11). _______________________________________________________ AFFIANT Sworn to and subscribed before me on this __________ day of______________________, ________ _______________________________________________________ NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com