IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS LAKE COUNTY, OHIO ___________________________________ CASE NO. __________________________________ Plaintiff/Petitioner v. JUDGE COLLEEN A. FALKOWSKI ____________________________________ AFFIDAVIT REGARDING PARENTING Defendant/Petitioner PROCEEDING 3109.27 INSTRUCTIONS If you need more space to answer any question, please atat asepch arate sheet of paper to the back of this form. If the answ toe thrsefollowing questions are not the same for all the children, a separate affidavit must be filed for each. child STATE OF OHIO ) )SS: COUNTY OF LAKE ) I , the undersigned, being first duly sworn, state that the following answers to the questions in this AFFIDAVIT aretrue. I understand that I have a continuing duty to informCourt the of any parenting proceedings concerning the child/childrenin this or any other state of which I obtain information during this proceeding. The names and dates of birth of the child/children for which this affidavit applies is/are: ___________________________________________________________ __________________________________________________________________________________________________ 1. Beginning with the child(ren)s present address, state the places where the child(ren) lived within the last fiveyears, and the names and present addresses of the persons with whom the child(ren) lived during that period. PART A PART B Places and Dates Provide the present residence address for each person listed in PART A.Living with: ___________________________________ Mothers Address: ________________________________Address: _______________________________________ _______________________________________________ From ____________________ To___________________ FathersAddress _________________________________ _______________________________________________ Living with: ___________________________________ Address: _______________________________________ Other __________________________________________ From ____________________ To___________________ ______________________________________________ Other __________________________________________ Living with: ___________________________________ _______________________________________________ Address: _______________________________________ Other __________________________________________ From ____________________ To___________________ _______________________________________________ 2. Have you participated as a party, witness, or in any other capacity, in any other litigation concerning the custodyand/or parenting time of the same child/children, or know of a party who has been convicted or pleaded guilty to any criminaloffense regarding child abuse or neglect, or determined to be the perpetrator thereof, in this or any other state? YES ____ NO ____ If yes, furnish details: _________________________________________________________________________________________________ __________________________________________________________________________________________________ Initialed ____________ Custody Affidavit Page 1 American LegalNet, Inc. www.USCourtForms.com>>>> 2 3. The following information, including the Courtaddress and Case s Number, is provided detailing any custodyand/or parenting time proceeding, or child abuse or neglect proceeding, concerning the child/children pending in a Court of this or any other state. If none, state none. _________________________________________________________________________________________________ ________________________________________________________________________ __________________________ 4. The following are the names and addresses of anyons not a party pers to the proceeding including grandparents,if relevant, who have physical custody of the child/children or who claim to have custody, parenting time or visitation rights with respect to the child/children: _________________________________________________________________________________________ ________ _________________________________________________________________________________________________ _______________________________________________________________________________________________ ___ ___________________________________________ AFFIANT Sworn to and subscribed before me this _________ day of _________________, 20_____. ____________________________________________ Notary Public 03/2005 Initialed ____________ Custody Affidavit Page 2 American LegalNet, Inc. www.USCourtForms.com