Effective April 11, 200 5 IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS MAHONING COUNTY, OHIO AFFIDAVIT APPLICATION FOR REGISTRATION Case No.:____________________ OF AN OUT-OF STATE [ ] CUSTODY [ ] VISITATION ORDER - UCCJEA In Re:____________________________________________________________________________________ _ ____________________________________________________________________________________ Name of child(ren) subject of the attached order Date(s) of birth (1). I, {full legal name} _____________________, residing at {list current address} , being swo rn according to law, am petitioning this Court to register the attached out-of -sta the te [ ] custody [ ] visitation order that has been issued by [indicate the __________________________________________________________________________________________ [ ] 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(D) 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 identifying information. (2). The name(s) and address(es) of any person(s) , other than myself, who have been awarded custody or visitation (parenting time) in the attached custody and/or visitation order are as follows {specify}: Name(s) Relationship to Child(ren) Address __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (3). This order has been registered in the following other jurisdiction(s) or State(s) {specify}: Jurisdiction/State Registration accepted/denied/pending {list only one} __________________________________________________________________________________________ __________________________________________________________________________________________ I understand I am swearing or affirming under oath to the best of my knowledge and belief, the attached order which I am seeking to register is in effect and has not been stayed or modified. I understand if I knowingly make a false statement to this regard I can be fined or imprisoned. ___________________________________ ___________________________________ Date Petitioner State of Ohio, County of _____________________________ss: Sworn to or affirmed and signed before me on this ________________ by __________________ _ ___ Date Notary Public My commission expires: ______________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 NOTICE: Attach two (2) copies of the order sought to be register ed with at least one of the orders being certified. INSTRUCTIONS TO THE CLERK Please serve a copy of this APPLICATION FOR REGISTRATION OF AN OUT-OF STATE ORDER to the individual(s) listed in item number two (2) by certified U.S. mail. NOTICE TO RECIPIENT An application for registration of an out-of-state custody or visitation order has been filed with this court. The registered order is enforceable in the same manner as a custody or visitation order issued by an Ohio court as of the date of registration. If you wish to contest the validity of the registered custody or visitation order, you must request a hearing with this court within thirty (30) days following service of this notice. If you fail to request a hearing to contest the registered custody or visitation order, then the order will be confirmed by this court and you will be precluded from contesting the registration with respect to any matter that could have been asserted. 4/11/05 American LegalNet, Inc. www.USCourtForms.com