C-20, Rev. 1/05 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Judge Sharon L. Kennedy Judge Eva D. Kessler : Case No. ___________________ : Judge: _________________ Plaintiff / 1st Petitioner Defendant / 2nd Petitioner SUPPLEMENTAL AFFIDAVIT 1. I am a parent of the following minor child(ren): Name Date of Birth ___________________ Name Date of Birth __________________ Name Date of Birth __________________ 2. The present address of my former spouse (the non-residential parent) is: ________________________________ ________________________________ ________________________________ 3. The non-residential parent a) ? has ? has not been convicted of or pleaded guilty to a violation of Ohio Revised Code Section 2919.25 (criminal domestic violence) involving a victim who, at the time of the commission of the offense, was a member of the family or household that is the subject of the proceedings in this case; b) ? has ? has not been convicted of or pleaded guilty to any other offense which caused harm to a victim who, at the time of the offense, was a member of the family or household that is the subject of the proceedings in this case; c) ? has ? has not been determined to be the person who committed an act which is the basis of a court finding that a child has been abused. American LegalNet, Inc. www.USCourtForms.com _________________________ Affiant (residential parent) Sworn to and subscribed before me this 20 day of , . ______________________ Notary Public My commission expires _________________________. NOTE: This affidavit is only required if you are requesting that your new address be withheld from the former spouse. If the response to each of the statements in question #3 is Ahas not@, the court will issue an order stating that the non-residential parent is to be sent a copy of this and any subsequent Notice of Intent to Relocate that is filed with the court. If the response to any of the statements in question #3 is Ahas@, the court will issue an order stating that the non-residential parent shall not be sent a copy of this or any future Notice of Intent to Relocate. The court will, however, send a notice to the non-residential parent that he/she may file a motion requesting a court hearing to determine whether it would be in the best interest of the child(ren) that he/she be given the new address, and whether the visitation order should be revised. American LegalNet, Inc. www.USCourtForms.com