IN THE COURT OF COMMON PLEAS GEAUGA COUNTY, OHIO _____________________________________ Plaintiff / Petitioner : CASE NO. _________________________ : JUDGE _________________________________ -vs_____________________________________ Defendant / Respondent / Petitioner : MAGISTRATE __________________________ : AFFIDAVIT REGARDING PARENTING PROCEEDING (R.C. §3127.23) : Instructions: If you need more space to answer any questions, please attach a separate sheet of paper to the back of this form. If the answers to the following questions are not the same for all the children, you must file a separate affidavit for each child. You must answer all questions. I, ______________________________________ , the undersigned, being first duly sworn, acknowledge and understand that I have a continuing duty to inform the Court of any child custody proceeding concerning the child or children in this or any other state that could affect this proceeding. My answers to the questions in this Affidavit are true. 1. What are the name(s) and date(s) of birth of the child or children to whom this affidavit applies? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2. Where and with whom did the child or children this affidavit applies to live within the last five years, and what are the names and present addresses of the persons the child or children lived with during that period? Begin your answer with the child or children’s present address: Part A: Places and Dates where child(ren) have lived in last five years: Part B: Present residence address for each person listed in Part A Living with ________________________ At: _______________________________ _______________________________ From _____________ To _____________ Mother’s address ______________________ ____________________________________ ____________________________________ Living with ________________________ At: _______________________________ _______________________________ From _____________ To _____________ Father’s address ______________________ ____________________________________ ____________________________________ Living with ________________________ At: _______________________________ _______________________________ From _____________ To _____________ Other_______________________________ ____________________________________ ____________________________________ American LegalNet, Inc. www.FormsWorkflow.com Living with ________________________ At: _______________________________ _______________________________ From _____________ To _____________ Other_______________________________ ____________________________________ ____________________________________ 3. Have you participated as a party, as a witness, or in any other capacity, in any other proceeding concerning the allocation, between the parents of the same child, of parental rights and responsibilities for the care of the child, including any designation of parenting time rights and the designation of the residential parent and legal custodian of the child, or that otherwise concerned the custody of or visitation with the same child? Yes _____ / No ______. If your answer is “YES” state, for each proceeding, the court in which that proceeding was or is pending, the case number, and the date of the child custody determination, if any: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 4. Do you know of any proceedings that could affect the current proceeding, including proceedings for enforcement of child custody determinations, proceedings relating to domestic violence or protection orders, proceedings to adjudicate the child as an abused, neglected, or dependent child, proceedings seeking termination of parental rights, and adoptions? Yes ____ / No _____. If your answer is “YES” state, for each proceeding, the court in which that proceeding is pending, the case number, and the nature of the proceeding: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 5. Do you know of any person who is not a party to this case (including grandparents, if relevant) who has physical custody of the child or children, or who claims to have custody, parenting time, or visitation rights with the child or children? Yes _____ / No _____. If your answer is “YES” state the name and address of each of those persons: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ________________________________________ AFFIANT Sworn to and subscribed before me, the undersigned Notary Public, this _________________ day of _______________________________, _____________ _______________________________________ Notary Public 11/08  American LegalNet, Inc. www.FormsWorkflow.com