DR616 Eff. 1/1/2015 COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Case No. Plaintiff/Petitioner Judge v./and Magistrate Defendant/Petitioner/Respondent Instructions: Check local court rules to determine when this form must be filed. By law, an affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court, including Dissolutions, Divorces and Domestic Violence Petitions. 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, add additional pages. PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A)) Affidavit of (Print Your Name) Check and complete ALL THAT APPLY: 1. I request that the court 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 to protect the health, safety, or liberty of myself and/or the child(ren). Minor child(ren) are subject to this case as follows: 2. Insert the information requested below for all minor or dependent children of this marriage. You must list the residences for all places where the children have lived for the last FIVE years. a. Child's Name: Date of Birth: Place of Birth: Sex: Check if Confidential Address Confidential? Address Confidential? Address Confidential? Address Confidential? Male Female Period of Residence to to to to present Person(s) With Whom Child Lived (name & address) Relationship American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 b. Child's Name: Date of Birth: Place of Birth: Sex: Male Female Check this box if the information requested below would be the same as in subsection 2a and skip to the next question. Period of Residence to to to to present Check if Confidential Address Confidential? Address Confidential? Address Confidential? Address Confidential? Person(s) With Whom Child Lived (name & address) Relationship c. Child's Name: Date of Birth: Place of Birth: Sex: Male Female Check this box if the information requested below would be the same as in subsection 2a and skip to the next question. Period of Residence to to to to present Check if Confidential Address Confidential? Address Confidential? Address Confidential? Address Confidential? Person(s) With Whom Child Lived (name & address) Relationship IF MORE SPACE IS NEEDED FOR ADDITIONAL CHILDREN, ATTACH A SEPARATE PAGE AND CHECK THIS BOX . 3. Participation in custody case(s): (Check only one box.) 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 visitation (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 of, or visitation (parenting time), with any child subject to this case. For each case in which you participated, give the following information: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 a. b. c. d. Name of each child: Type of case: Court and State: Date and court order or judgment (if any): IF MORE SPACE IS NEEDED FOR ADDITIONAL CUSTODY CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX . 4. Information about other civil case(s) that could affect this case: (Check only one box.) I HAVE NO INFORMATION about any other civil 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. I HAVE THE FOLLOWING INFORMATION concerning other civil 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 a child subject to this case. Do not repeat cases already listed in Paragraph 3. Explain: Name of each child: Type of case: Court and State: Date and court order or judgment (if any): a. b. c. d. IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX . 5. Information about criminal case(s): List all of the 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 domestic violence 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 Convicted of What Crime? IF MORE SPACE IS NEEDED FOR ADDITIONAL CASES, ATTACH A SEPARATE PAGE AND CHECK THIS BOX . American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 6. Persons not a party to this case who has physical custody or claims to have custody or visitation rights to children subject to this case: (Check only one box.) I DO NOT KNOW OF ANY PERSON(S) not a party to this case who has/have physical custody or claim(s) to have custody or visitation 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 claim(s) to have custody or visitation rights with respect to any child subject to this case. a. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: b. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: c. Name/Address of Person Has physical custody Claims custody rights Claims visitation rights Name of each child: OATH (Do Not Sign Until Notary is Present) I, (print name) , swear or affirm that I have read this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature Subscribed and duly sworn before me according to law, by the above named applicant this ______ day of _______________________, _______, at _______________________, County of ___________________________, State of Ohio. ______________________________________ Signature of person