IN THE COURT OF COMMON PLEAS, GREENE COUNTY, OHIO DOMESTIC RELATIONS DIVISION _____________________________________ Plaintiff/Petitioner Vs. _____________________________________ : : : : : : Case No. ___________________ JUDGE STEVEN HURLEY AFFIDAVIT (Pursuant to O.R.C. 3109.27 – Defendant/Petitioner : Child Custody Information) ____________________________________________________________________________________________________________ [Answers requiring additional space should be continued on the back. If the answers are not the same for all children, a separate Affidavit must be filed for each child] STATE OF OHIO, COUNTY OF GREENE, SS: I, ___________________________, being first duly sworn, state that the answers to the following questions are true. The following minor children are the same as those listed in the accompanying pleading and are those on whom I request a custody order: ____________________________________________________________________________ __________________________________________________________________________________________________ Where (giving the date of the beginning of this residence) and with whom is/are the child(ren) now living? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Where (giving the dates of residence for each place) and with whom has/have the child(ren) lived in the past 5 years? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you participated as a party, witness or in any other capacity in any other litigation concerning the custody of the child(ren) in this or any other state? _______________________________________________________________ __________________________________________________________________________________________________ State any information you have about any custody proceeding concerning the child(ren) pending in a Court of this or any other state. Include the case numbers, the name of the Court, and the address of the Court. __________________________________________________________________________________________________ State the name and address of any person not a party to the proceedings who has physical custody of the child(ren) or who claims to have custody or visitation rights with respect to the child(ren). ______________________________ __________________________________________________________________________________________________ Are you now, or have you ever been, a party to any civil or criminal case or investigation concerning child abuse, child neglect, or domestic violence? If so, state the case name(s), case number(s), date(s), and nature of the case(s). __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ I understand that I have a continuing duty to inform the Court of any custody proceedings concerning the child(ren) in this or any other state of which I obtain information during this proceeding. _______________________________________ AFFIANT SWORN TO AND SUBSCRIBED BEFORE ME THIS ___ DAY OF ____________, 20___. ___________________________________________ NOTARY PUBLIC American LegalNet, Inc. www.USCourtForms.com