PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE ADOPTION OF ____________________________________________________ CASE NO. _______________________ AFFIDAVIT [R.C. 3127.23] State of Ohio, County of ______________________________________________s.s. (To be filed only when guardianship of the person of a minor is sought.) Affiant being first duly sworn, deposes and says: 1. That the child's present address, the places where the child has lived within the last five years, and the names and present addresses of the person(s) with whom the child has lived during that period are: 2. That affiant has (not) participated as a party, witness, or in any other capacity in any litigation concerning the custody of the child(ren) in this or any other state. 3. That affiant has (no) information of any custody proceeding concerning the child(ren) pending in a court of this or any other state, except ______________________ _______________________________________________________________________. 4. That affiant has (no) knowledge of any person not a party to the proceedings who has physical custody of the child(ren) or claims to have custody or visitation rights with respect to the child(ren). If 2, 3, or 4 is answered in the affirmative, and the space afforded is insufficient for full explanation, please attach and incorporate herein any necessary information. Affiant realizes that affiant has a continuing duty to inform the Court of any custody proceedings concerning the child(ren) in this or any other state of which affiant obtains information during the pendency of this proceeding. ____________________________________ Sworn to before me and subscribed in my presence this ________ day of ___________________, _________. ____________________________________ Notary Public FORM 16.1 - AFFIDAVIT Eff. Date March 1, 2008 American LegalNet, Inc. www.FormsWorkflow.com