PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE ADOPTION OF (Name after adoption) CASE NO. AFFIDAVIT (R.C. 3109.27) State of Ohio, County of S.S. Upon being duly sworn. state the following: does hereby (Name) 1. The child(ren) involved is/are 2. The child(ren)'s present address is/are 3. The places where the child(ren) has/have lived the last five years are 4. The names and present addresses of the persons with whom the child(ren) has/have lived during that period is/are 5. I have/have not participated as a party, witness, or in any other capacity or any other litigation concerning the allocation of parental rights and responsibilities of the same child(ren) or that otherwise concerned the custody in this or any other State. 6. I have/have no information of any parenting proceeding concerning the child(ren) pending in a court of this or any other State. 7. I know/do not know person(s) not a party to the proceeding concerning the child(ren) or claims to be a parent of the child(ren) who is designated the residential parent and legal custodian of the child(ren or to have visitation rights with respect to the child(ren) or any person other than a parent of the child(ren) who has custody or visitation rights with respect to the child(ren). 8. I have/have not been convicted of or pleaded guilty to any criminal offense involving any act that resulted in a child being abused or neglected nor have I been the perpetrator of the abusive or neglectful act that was the basis of an adjudication that a child is an abused or neglected child. If your declarations in statements 5 through 8 are in the affirmative, state the case name(s), case number(s), date(s) and nature of the cases(s) Sworn to before me and subscribed in my presence this day of , . Notary Public H.C. FORM 118.10 - AFFIDAVIT 02/10/03 American LegalNet, Inc. www.FormsWorkflow.com