COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.STATEOFOHIO:IN THE COURT OF COMMON PLEAS FAMILY COURT DIVISION SS: STARKCOUNTY: INRE:Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)CASENO. :::::AFFIDAVIT IN COMPLIANCE WITH UNIFORM CHILD CUSTODY JURISDICTION ACT (RC 3109.27) being duly sworn according to law, says that these proceedings involve the custody of a child, or children, and avers an follows: (1) Thechildreninvolvedare:CURRENTPLACEOFRESIDENCE BIRTHDATE NAME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Five-year history of residence and custody: (2) FROMRESIDED WITHRESIDEDATTOTHE PEOPLE OF THE STATE OF NEW YORK TO(3)Have you participated as a party, witness, or otherwise in any other action involving the custody ofthese children:If yes, state: Nature of action CaseNo.Parties DateGREETINGS:Title of other court disposition Are there how pending proceedings in any court:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableIf yes, state: (4),located at County ofCaseNo. Title of other CourtFiling date (5) Doanyotherpersonshaveaninterestincustodyorvisitation: Ifyes,stateo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomNameAddressNature of interest Haveyouoryourspousebeenconvicted oforpledguiltyto anycriminaloffense involving any act which resultedina child beinganabusedor neglected child? (6)Ifyes,state: CaseNo.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.PartiesNature of action Date (7) Have you or your spouse been determined to be the perpetrator of any act that causedachildtobeadjudicatedanabusedorneglectedchild?Ifyes,state: DateCaseNo.PartiesNature of action (8) Theundersigned isin active duty with the U.S. military?, one of the Justices of theno yes (9)Court in Witness, Honorableday of, 20 County,Otherappropriateinformation: Have you or your spouse ever been convicted of or plead guilty to a charge of Domestic Violence (O.R.C. 2919.25) involving a victim who at the time of the commission of the offense was a member of the family or household that Is the (10) subjectofthisproceeding?(Attorney must sign above and type name below)If yes state:Have you or your spouse ever been convicted of or plead guilty to any other offense involving avictim whoatthe time of thecommission of the offense was a member ofthe familyor household that in the subject of this proceeding, and (11) causedphysicalharmtothevictiminthecommissionoftheoffense?Attorney(s) forIfyes state:I understand that I have a continuing duty to inform the Court of any custody proceedingsconcerningthischild,inthisoranyotherstate,ofwhichIobtain information duringthis proceeding.Office and P.O. Address,20 day of Executed at,Ohio,thisTelephone No.: Facsimile No.: E-Mail Address:Affiant Sworn to before me andsubscribedin my presence this dayand date. Notary PublicMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com