PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF THE PLACEMENT OF (Current name of child) CASE NO. AFFIDAVIT [R.C. 3127.23] State of Ohio, County of BU TLER s.s. Affiant being first duly sworn, deposes and says: 1. That the child's present address, the place(s) where the child has lived within the last five years, and the nam e and present address of each person with whom the child has lived during that period are: 2. That affiant has (not) participated as a party, witness, or in any other capacity in any proceeding concerning the allocation, between the parents of the sam e child, of parental rights and responsibilities for the care of the child including any designation of parenting tim e rights and the designation of the residential parent and legal custodian of the child or that otherwise concerned the custody of or visitation with the sam e child and, if so, the court, case num ber and the date of the child custody determ ination are attached. That affiant has (no) inform ation of any proceeding that could affect the current proceeding, including proceedings for enforcem ent of child custody determ inations, proceedings relating to dom estic violence or protection orders, proceedings to adjudicate the child as an abused, neglected, or dependent child, proceedings seeking term ination of parental rights, and adoptions, and, if so, the court, the case num ber, and the nature of the proceeding are attached. That affiant has (no) knowledge of any person who is not a party to the proceedings and has physical custody of the child or claim s to be a parent of the child who is designated the residential parent and legal custodian of the child or to have parenting tim e rights with respect to the child or to be a person other than a parent of the child who has custody or visitation rights with respect to the child and, if so, the nam es and addresses of those persons are attached. That affiant has (not) been previously convicted of or pleaded guilty to any crim inal offense involving any act that resulted in a child being an abused child or a neglected child or previously been determ ined, in a case in which a child has been adjudicated an abused child or a neglected child, to be the perpetrator of the abusive or neglectful act that was the basis of the adjudication. 3. 4. 5. If 2, 3, 4 or 5 is answered in the affirm ative, and the space afforded is insufficient for full explanation, please attach and incorporate herein any necessary inform ation. Affiant realizes that (s)he has a continuing duty to inform the Court of any parenting proceeding concerning the child in this or any other state of which affiant obtains inform ation during the pendency of this proceeding. Signature of Affiant Sworn to before m e and subscribed in m y presence this day of , . Notary Public BCPC FORM 308 - AFFIDAVIT - PDF 6/20/2007 American LegalNet, Inc. www.FormsWorkFlow.com