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Child Custody Affidavit Form. This is a Ohio form and can be use in Greene County (Court Of Common Pleas).
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Tags: Child Custody Affidavit, Ohio County (Court Of Common Pleas), Greene
IN THE COMMON PLEAS COURT OF GREENE COUNTY, OHIO
DOMESTIC RELATIONS DIVISION
___________________________________
Plaintiff/Petitioner
Case No._____________
Judge Steven L. Hurley
-vsCHILD CUSTODY AFFIDAVIT
__________________________________
Defendant/Petitioner
_____________________________________________________________________________
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 3127.23(0) 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) are subject to this proceeding as follows:
(Insert the information requested below. The residence information must be given for the last FIVE years.)
a. Child's name
Period of residence
To Present
Place of birth
Address
Confidential
I Date of birth
Person child lived with (name & address)
Sex
Relationship
From
To
From
To
From
To
From
To
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a. Child's name
Period of residence
to Present
Place of birth
Address
Confidential
Date of birth
Person child lived with (name & address)
Sex
Relationship
From
To
From
To
From
To
a. Child's name
Period of residence
to Present
Place of birth
Address
Confidential
Date of birth
Sex
Person child lived with (name & address) Relationship
From
To
From
To
From
To
From
To
b. Additional children are listed on an attached addendum. (Provide all information for additional
children on an attachment.)
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 each child__________________________________________________________________
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 proceedings relating 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 this proceeding.
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______ I HAVE THE FOLLOWING INFORMATION concerning proceedings that could affect the
current proceeding, including any proceedings relating to custody, domestic violence or protection orders,
dependency, neglect or abuse allegations, convictions 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_________________________________________________
c. Type of proceeding__________________________________________________________________
d. Court and state______________________________________________________________________
e. 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 whom 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:
(See next page)
a. Name and address of person
_____________________________________________________________
( ) has physical custody
( ) claims custody rights
( ) claims visitation rights
Name of each child
_______________________________________________________________________
b. Name and address of person
_____________________________________________________________
( ) has physical custody ( ) claims custody rights
( ) claims visitation rights
Name of each child
_______________________________________________________________________
c. Name and address of person
_____________________________________________________________
( ) has physical custody ( ) claims custody rights
( ) claims visitation rights
Name of each child
_______________________________________________________________________
6. Knowledge of prior child support proceedings: (Check only one)
______ The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this
or any state or territory
______ The child(ren) described in this affidavit 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):
___________________________________________________________________________
e. Amount of child support paid and by whom:
___________________________________________________________________________
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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 neglect, or
dependency) concerning the child(ren) in this state or any other state about which information is
obtained during this proceeding.
I certify that a copy of this document was (Check only one)
( ) Filed with initial pleadings.
( ) hand delivered to the person(s) listed below on
(date ____________________________________)
( ) mailed
(
) faxed and mailed
Other party or his/her attorney:
Name:_____________________________________________Address:___________________________
City, State, Zip:_______________________________________ Fax Number _____________________
I understand that I am swearing or affirming under oath to the truthfulness of the statements made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated:___________________
____________________________________________________
Signature of Party
Printed name: _______________________________________
Address:____________________________________________
City, State, Zip: ______________________________________
Phone:_________________Fax:_______________
STATE OF OHIO
COUNTY OF _____________________________
Sworn to or affirmed and signed before me on _______________________by
________________________________________________
____________________________________________
Notary Public
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