IN THE COURT OF COMMON PLEAS COUNTY OF CUYAHOGA JUVENILE DIVISION In the Matter of: D.O.B. D.O.B. D.O.B. D.O.B. Mother: Address Phone: Phone: Father: Father of: Address Phone: APPLICATION TO DETERMINE CUSTODY PARENTING TIME SHARED PARENTING PLAN COMPANIONSHIP AND VISITATION Judge: Father: Father of: Address Case Number(s): Now comes, (your name) , , pursuant to R.C. 2151.23(A)(2) and (relationship to child) makes application to the court to determine the custody establish parenting time establish companionship and visitation establish a shared parenting plan of the above named child(ren). In addition the undersigned prays this Honorable Court grant an order of support, including an order regarding health insurance or cash medical support for the child. The reasons for this request are more fully explained in the attached affidavit. Applicant, Pro Se Address State Phone Number E-mail address City Zip Code American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT I, (your name) , the applicant in the above captioned matter, duly sworn deposes and states the following: 1. The child(ren)'s last known or present address is in Cuyahoga County. 2. The last time the child(ren) resided at that address was (date) . 3. Paternity was established on (date) by Cuyahoga Job and Family Services, Office of Child Support Services in case number the Cuyahoga County Court of Common Pleas, Juvenile Court Division in case number a voluntary acknowledgement of paternity signed and on file with the Central Paternity Registry. 4. Child support has been ordered to be paid by to or assigns by the Cuyahoga Job and Family Services, Office of Child Support Services Cuyahoga County Court of Common Pleas, Juvenile Court Division Cuyahoga County Court of Common Pleas, Division of Domestic Relations. The current child support order for this child is attached at Exhibit . 5. That I desire custody, parenting time, shared parenting or visitation with the child because (be specific) 6. That it is in the best interest of the child(ren) for the court to determine the child(ren)'s custody, parenting time, shared parenting or visitation. 7. That the child(ren) is/are not wards of another state and do not have a court case relative to their custody in another court of this state. 8. That there is not a protection order in effect preventing me from having contact with the child(ren). That there is a protection order in effect preventing me from having contact with the child(ren). 9. That I have attached a Uniform Child Custody Jurisdiction and Enforcement Act Affidavit to this pleading and it is incorporated herein as though fully rewritten. Applicant Signature Sworn to before me this day of , 20 . _________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com