FORM 10.01-F: INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT IN THE COURT COUNTY, OHIO : Case No. Petitioner : : Judge: v. : INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A)) : Respondent (Filed with Petition for Domestic Violence Civil Protection Order) NOTE: 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 a Petition for a Domestic Violence Civil Protection Order. 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, attach an additional page. I (full legal name) , being sworn according to law, certify these cases involve the custody of a child or children and the following statements are true: 1. 2. I am requesting the Court to 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 in that the health, safety, or liberty of myself and/or the child(ren) would be jeopardized by the disclosure of the identifying information. (Number): Minor child(ren) are subject to this case as follows: (Insert the information requested below. The residence information must be given for the last FIVE years.) a. Child’s name Period of residence to present Place of birth Address Confidential Person child lived with (name & address) Date of birth Sex Relationship Address Confidential to Address Confidential to Address Confidential to Address Confidential FORM 10.01-F: INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 2 of Form 10.01-F] Case No.________________________ b. Child’s name Period of residence Place of birth Address Confidential to present Address Confidential to Relationship Address Confidential to Person child lived with (name & address) Sex Address Confidential to Date of birth Address Confidential c. Child’s name Period of residence Place of birth Address Confidential to present Address Confidential to Relationship Address Confidential to Sex Address Confidential to Person child lived with (name & address) Date of birth Address Confidential e. Additional children are listed on Attachment 2(d). (Provide requested information for additional children on an attachment labeled 2d.) 3. Participation in custody case(s): (only one) 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. Explain: a. b. c. d. Name of each child Type of case Court and State Date and court order or judgment (if any): FORM 10.01-F: INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 3 of Form 10.01-F] Case No.________________________ 4. Information about custody case(s): (only one) I HAVE NO INFORMATION of any cases that could affect the current case, 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 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, other than listed in Paragraph 3. Explain: a. b. c. d. 5. 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 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 6. Name of each child Type of case Court and state Date of court order or judgment (if any): CASE NUMBER COURT/STATE/COUNTY CHARGE Persons not a party to this case: (only one) I DO NOT KNOW OF ANY PERSON not a party to this case who has physical custody or claims 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 and address of person has physical custody claims custody rights claims visitation rights claims custody rights claims visitation rights Name of each child b. Name and address of person has physical custody Name of each child c. Name and address of person has physical custody claims custody rights claims visitation rights Name of each child FORM 10.01-F: INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 4 of Form 10.01-F] Case No.________________________ 7. I understand that I have a continuing duty to advise this Court of any custody, visitation, parenting time, divorce, dissolution of marriage, separation, neglect, abuse, dependency, guardianship, parentage, termination of parental rights, or protection from domestic violence case concerning the child(ren) in this state or any other state about which information is obtained during this case. OATH OF AFFIANT I hereby swear or affirm that the answers above are true, complete, and accurate to the best of my knowledge. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury under R.C. 2921.11. AFFIANT Sworn to and subscribed before me on this day of , NOTARY PUBLIC FORM 10.01-F: INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com