STATE OF OHIO, COUNTY IN THE COURT OF COMMON PLEAS JUVENILE DIVISION ___________________________________________ CASE NO. __________________________ PLAINTIFF/PETITIONER (1) SS# DOB ______________ JUDGE _____________________________ ADDRESS MAGISTRATE ______________________ v. ___________________________________________ DEFENDANT/PETITIONER (2)/RESPONDENT SS# ________________ ADDRESS INFORMATION FOR PARENTING PROCEEDING (O.R.C. 3109.27) DOB ______________ _______________________________ ___________________________ Notes: By law, this affidavit must be filed and served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court. Each party has a continuing duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other Court in this or any other state. If more space is needed, attach an additional page. Affiant ___________________________________ states as follows: 1. The name, birth date, Social Security Number (if any) of each child whose custody/visitation is at issue in this case is: ______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 2. The present home address of the child(ren) is: _________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 3. The child(ren) currently reside(s) with what adult(s)? ___________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 4. All other places and dates where the child(ren) have lived during the last 5 years, and the names of all adult(s) with whom they lived at each address are as follows: ___________________________ _______________________________________________________________________________ _______________________________________________________________________________ 6 American LegalNet, Inc. www.USCourtForms.com 5. The name(s) and current address of all adults listed above are: ____________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 6. Do you know of any litigation anywhere, past or present, which concerns the custody, visitation, or care of the child(ren)? ____________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 7. If the answer to #6 is “yes”, state any other information you have about any parenting proceeding concerning the child(ren) now pending in a Court of this or any other state. Include the case number, the name of the Court and the address of the Court. ______________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 8. State the name and address of any person who is not a party to this proceeding: (A) who has physical possession of the child(ren) or (B) who claims to be a parent of the child(ren) and is either the residential parent and legal custodian, or has visitation rights with the child(ren), or (C) who is a person other than a parent of the child(ren) who has custody or visitation rights. _____________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 9. Are you now, or have you ever been, a party to any civil or criminal case or any investigation concerning child abuse, child neglect, or domestic violence? If so, state each Court, case name, case number, date, nature and outcome of the case: _____________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 10. Do you have any domestic violence protection orders or any other restraining orders issued against you, or on your behalf against any other person? If so, state each Court, case name, case number, date and nature and outcome of the case: _____________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 7 American LegalNet, Inc. www.USCourtForms.com OATH OF AFFIANT I hereby swear or affirm that the answers above are true, complete and accurate. I understand that falsification of this document may result in a Contempt of Court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.11). ___________________________________________ AFFIANT Sworn to and subscribed before me on this day of , 20____ ___________________________________________ NOTARY PUBLIC 8 American LegalNet, Inc. www.USCourtForms.com STATE OF OHIO, ____________________ COUNTY, SS: IN THE COURT OF COMMON PLEAS JUVENILE DIVISION CASE NO.: ________________________ ________________________________ Plaintiff vs. REQUEST FOR SERVICE ________________________________ Defendant TO THE CLERK OF SAID COURT: Make service on the following parties: (Names and Adresses Shown) by ( ) Certified Mail, Return Receipt Requested ( ) Addressee Only, Certified Mail, Return Receipt Requested ( ) Ordinary Mail ( ) Issuance to Sheriff of ________________________ County, Ohio For (Personal) or (Residence) service ( ) $15.00 additional Deposit attached for costs of issuance to foreign Sheriff ( ) Other: Specify ______________________________________________ SPECIAL INSTRUCTIONS TO SHERIFF: _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 9 American LegalNet, Inc. www.USCourtForms.com