PARENTING PROCEEDING AFFIDAVIT/CUSTODY AFFIDAVIT Ohio Revised Code 31et seq., esp. 3109.27 The undersigned hereby affirms under oath or pain and penalty of perjury that the following information concerning the children affected by this action is true to the best of his or her knowledge: 1. The children involved are: Date of Birth Name 1. 2. 3. 4. 5. 2. Current Residence Five year history of residence and custody From To Reside With Reside at 3. Have you participated as a party, witness or otherwise in any other action involving the custody of these children? (Indicate “yes” or “no”. if “yes” please indicate Date, Case No., Parties, Nature of Action, Disposition, and Title of other Court.) 4. Are there now pending proceedings in any Court? (Please indicate “yes” or “no”. if “yes” please indicate Title of other Court, Case no., and Filing Date) 5. Do you know of any other persons not a party to this action who have a Court ordered interest in parenting or visitation? (Please indicate “yes” or “no”. if “yes” please give the other person’s name. Address, nature of the interest, name of Court, and case number) 6. Have you ever been convicted of, or pleaded guilty to any criminal offense involving any act that resulted in a child being an abused or neglected child, or has it previously been determined, or, in a case in which a child has been adjudicated an abused or neglected child, were you determined to be the perpetrator of the abusive or neglectful act that was the basis of the adjudication? (Please indicate “yes” or “no”. if “yes” please give the date, name of Court, case number, and the title of the case) 7. Other appropriate information: Executed at ___________________________, Ohio, this ________day of ___________________________, 20____. ___________________________________________ Affiant Sworn to before me and subscribed in my presence this day and date. ___________________________________________ Notary Public