IN THE COURT OF COMMON PLEAS JUVENILE DIVISION CUYAHOGA COUNTY, OHIO IN THE MATTER OF: CASE NUMBER: CHILD(REN) OF: JUDGE: Mother UCCJEA AFFIDAVIT R.C. 3127.23 Father I, (full legal name) _____________________________________________, being sworn according to law, certify that these proceedings involve the custody of a child, or children and the following statements are true: 1. I am requesting the court to not disclose my address or that of the child/ren. My address is confidential pursuant to ORC 3127.23D 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. 2. (Number): _______ minor child/ren is/are subject to this proceeding as follows: (Insert the information requested below. The residence information must be given for the last FIVE years.) Child's Name Date of Birth Period of Residence to present to to to to Address Place of Birth Gender Check if Confidential Person with whom child lived Relationship American LegalNet, Inc. www.FormsWorkFlow.com Child's Name Date of Birth Period of Residence to present to to to to Address Place of Birth Gender Check if Confidential Person with whom child lived Relationship Child's Name Date of Birth Period of Residence to present to to to to Address Place of Birth Gender Check if Confidential Person with whom child lived Relationship Child's Name Date of Birth Period of Residence to present to to to to Address Place of Birth Gender Check if Confidential Person with whom child lived Relationship 3. Participation in custody proceeding(s) (check only one) I HAVE NOT participated as a party, witness, or in any capacity in any other litigation, in this or any other state, concerning the custody of or visitation (parenting time) with any child subject to this proceeding. I HAVE participated as a party, witness, or in any capacity in any other litigation, in this or any other state, concerning the custody of or visitation (parenting time) with any child subject to this proceeding. Explain: a. Name of child American LegalNet, Inc. www.FormsWorkFlow.com b. Type of proceeding c. Court and State d. Date of Court order or judgment (if any) 4. Information about custody proceeding/s: (check only one) I HAVE NO INFORMATION of any proceedings that could affect the current proceeding, including any proceeding related to custody, domestic violence or protection orders, dependency, neglect or abuse allegations, or that a parent or any member of their household has been convicted of a sexually oriented offense or adoptions concerning any child subject to these proceedings. I HAVE THE FOLLOWING INFORMATION concerning proceedings that could affect the current proceeding, including any proceedings relating to custody, domestic violence or protections orders, dependency, neglect or abuse allegations or that a parent or any member of their household has been convicted of a sexually oriented offense or adoptions concerning any child subject to this proceeding, other than set out in item 3. Explain: a. Name of each child b. Name of parent or member of household b. Type of Proceeding c. Court and State d. Date of court order or judgment (if any) 5. Persons not a party to this proceeding: (check only one) I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or claims to have custody or visitation rights with respect to any child subject to this proceeding. I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this proceeding: a. Name and address of person has physical custody claims custody rights Name of each child claims visitation rights American LegalNet, Inc. www.FormsWorkFlow.com b. Name and address of person claims custody rights has physical custody Name of each child claims visitation rights c. Name and address of person has physical custody claims custody rights Name of each child claims visitation rights 6. Knowledge of prior child support proceeding: (check only one) The child/ren described in this affidavit is/are not subject to existing child support order/s in this or any state or territory. The child/ren described in this affidavit IS/ARE subject to the following existing child support order/s. a. Name of each child ___________________________________________________________ b. Type of proceeding _______________________________________________________________ c. Court and Address _______________________________________________________________ d. Date of court order or judgment (if any): _____________________________________________ d. Amount of child support paid and by whom: ___________________________________________ 7. I acknowledge that I have a continuing duty to advise this Court of any custody, visitation, child support, or guardianship proceeding (including dissolution of marriage, child abuse, neglect, or dependency) concerning the child/ren in this state or other state about which information is obtained during this proceeding. American LegalNet, Inc. www.FormsWorkFlow.com I understand that I am swearing or affirming under oath to the truthfulness of the statement made in this affidavit and that the punishment for knowingly making a false statement includes fine and/or imprisonment. Signature of Party Date _ _____ ________________________________________ _______________________________________ ______ __ Printed Name Address, City, State, and Zip Code _____________________________________ Phone Number SWORN TO ME THIS _______ DAY OF ___________________, 20______. _________________________________ NOTARY PUBLIC/DEPUTY CLERK Seal here American LegalNet, Inc. www.FormsWorkFlow.com