COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO ___________________________________ PLAINTIFF : CASE NO. _____________________________ : JUDGE ________________________________ vs : ___________________________________ DEFENDANT NOTICE OF INTENT TO RELOCATE O.R.C. 3109.051(G) : By prior order of this court dated ________________________, I was designated the Residential Parent and Legal Custodian and my former spouse, the non-residential parent, was allocated visitation rights with respect to the following children: (Names and Birth Dates) ____________________________________________________________________ _________________________________________________________________________________________ I hereby give notice, in accordance with O.R.C. 3109.051(G) of my intent to relocate From: ___________________________________________________________________________ Residence address specified in last order To: ___________________________________________________________________________ New residence address CHECK THE APPROPRIATE PARAGRAPH By prior order of court found at Volume ________ Page ________, it was determined that (name) ________________________, the non-residential parent, is entitled to a copy of this notice. Address of non-residential parent: ____________________________________________________________ OR By prior order of court found at Volume ________ Page ________, it was determined that (name) ________________________, the non-residential parent, shall not be mailed a copy of this notice. _______________________________________ Residential Parent ************************************************************************************* WAIVER I ____________________ (non-residential parent) acknowledge that _____________________ (residential parent) has notified me of his/her intent to relocate to the residence listed above. I hereby waive my right to be sent a copy of this notice by the court. _______________________________________ Non-Residential Parent (Notary required for waiver only) Sworn to and subscribed before me this ________ day of ________________________, 20____. _______________________________________ Notary DR0706101 Notice of Intent to Relocate with Affidavit of Residential Parent and Legal Custodian American LegalNet, Inc. www.FormsWorkflow.com STATE OF OHIO CUYAHOGA COUNTY ) ) ) SS: AFFIDAVIT ________________________ being first duly sworn, states the following answers to the questions set out herein: 1. State whether the non-residential parent ________________________ has ever been convicted of or pleaded guilty to a violation of §2919.25 of the Ohio Revised Code (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 proceeding in this case. YES NO If yes, give name of court, date and case number. ____________________________________________________________________________________ 2. State whether the non-residential parent ________________________ has ever been convicted of or pleaded guilty to any other offense 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 proceeding in this case and caused physical harm to the victim in the commission of the offense. YES NO If yes, give name of court, date and case number. ____________________________________________________________________________________ 3. State whether the non-residential parent has been determined to be the perpetrator of the abuse act that is the basis of an adjudication that a child is an abused child. YES NO If yes, give name of court, date and case number. ____________________________________________________________________________________ ________________________________________ Affiant Sworn and subscribed before me this ________ day of ________________________, 20________. ________________________________________ Notary American LegalNet, Inc. www.FormsWorkflow.com