4/11/05 IN THE COURT OF COMMON PLEAS COLUMBIANA COUNTY, OHIO AFFIDAVIT APPLICATION FOR REGISTRATION Case No.: __________________________ OF AN OUT-OF STATE[ ] CUSTODY[ ] VISITATION ORDER UCCJEA In Re:__________________________________________________________________ ______________________ ________________________________________________________________________ ____________________ Name of child(ren) subject of the attached order Date(s) of birth (1). I, {full legal name} ___________________________ ,residing at {list current address} _______________ ___________________________________________________________, being sworn according to law, am petitioning this Court to register the attached out-of -state [ ] custody [ ] visitation order that has been issued by [indicate the court, state or other jurisdiction and date]: ________________________________________________________________________ ____________________ [ ] I am requesting the court to not disclose my address or that of the child(ren). My address is confidential pursuant to ORC 3127.23(0) 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 identifying infor mation. (2). The name(s) and address(es) of any person(s), other than my self, who have been awarded custody or visitation (parenting time) in the attached custody and/or visitation order are a s follows {specify}: Name(s) Relationship to Child(ren) Address ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ (3). This order has been registered in the following other jurisdiction(s) or State(s) {specify}: Jurisdiction/State Registrationaccepted/denied/pending {list only one} ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ I understand I am swearing or affirming under oath to the best of my knowledge and belief, the attached order which I am seeking to register is in effect and has not been stayed or modified. I understand if I knowingly make a false statement to this regard I can be fined or imprisoned. __________________________________ ____________________________________ Date Petitioner State of Ohio, County of __________________________________________ss: Sworn to or affirmed and signed before me on this ______________by______ ___________________________ Date Notary Public My commission expires: __________________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 4/11/05 NOTICE: Attach two (2) copies of the order sought to be registered with at least one of the orders being certified. INSTRUCTIONS TO THE CLERK Please serve a copy of this APPLICATION FOR REGISTRATION OF AN OUT-OF STATE ORDER to the individual(s) listed in item number two (2) by certified U.S. mail. NOTICE TO RECIPIENT An application for registration of an out-of-state custody or visitation order has been filed with this court. The registered order is enforceable in the same manner as a custody or visit ation order issued by an Ohio court as of the date of registration. If you wish to contest the validity of the registe red custody or visitation order, you request a musthearing with this court within thirty (30) days following service of this notice. If you fail to request a hearing to contest the registered custody or visitation order, then the order will be confirmed by this court and you will be prec luded from contesting the registration with respect to any matter that could have b een asserted. 4/11/05 American LegalNet, Inc. www.USCourtForms.com