IN THE WARREN COUNTY, OHIO COMMON PLEAS COURT JUVENILE DIVISION _______________________________ : CASE NO.____________________ Plaintiff/Petitioner (1) : (dob:___________) ____________________________ : ____________________________ Address : vs. : INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT (O.R.C. 3127.23) ____________________________ : Defendant/Petitioner (2) (dob:__________) : ____________________________ : ____________________________ : Address ______________________________________________________________________ By law, this affidavit must be filed and served with the first pleading filed by each party in every parenting [custody/visitation (now known as parenting time)] 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. I, ______________________________________, state as follows: (Name) 1. List all minor children of the parties: Name___________________________ Date of Birth___________________ Name___________________________ Date of Birth___________________ Name___________________________ Date of Birth___________________ Name___________________________ Date of Birth___________________ 2. Children listed in #1 above are currently living at what address? ________________________________________________________________ Since when?___________________ 3. Complete the following information for each adult living at the address in #2 above. American LegalNet, Inc. www.FormsWorkFlow.com Name___________________________ Relationship to Child(ren)_________ Name___________________________ Relationship to Child(ren)_________ Name___________________________ Relationship to Child(ren)_________ Name___________________________ Relationship to Child(ren)_________ 4. Children listed in #1 above have been enrolled in the ______________________ School district since _______________________ (month and year of enrollment). 5. List all addresses for the children in #1 for the last 5 years. From (date) to (date) Address Name of Adults in Household 6. List the name and address of any person who is not a party to this proceeding: (A) who has physical custody of the child(ren); or (B) who claims to be a parent of the child(ren) and who is designated the residential parent and legal custodian; (C) claims to have parenting time rights with the child(ren); or (D) who is a person other than a parent of the child(ren) who has custody or visitation rights with the child(ren). Name Address 7. Have you ever been a party, witness or otherwise involved in any case involving the custody, parenting time rights, or visitation of any child listed in #1? Yes Court or Agency No If yes, complete the following: Address of Court or Agency Case Number Date(s) of custody determination, if any 8. Do you know of any proceedings that could affect the current proceeding, including proceedings for enforcement of child custody determinations, proceedings relating to domestic violence or protection orders, proceedings to adjudicate the child as an abused, neglected, or dependent child, proceedings seeking termination of parental rights, and adoptions, and if so, the court, the case number, and the nature of the proceeding. American LegalNet, Inc. www.FormsWorkFlow.com Court Case Number Nature of Proceeding 9. Complete the following information for any civil or criminal case or investigation concerning child abuse, or child neglect to which you have ever been a party. Court or Agency Name Case Number Outcome of Case or Investigation 10. List all of the criminal convictions including guilty pleas for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm to the victim during the commission of the offense. Name Case Number Court/State/County Charge 11. 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, complete the following: Name of Court Name of Case/Case Number Date of Filing Nature and Outcome of Case 12. Are there any child support orders in effect? Name of Court Name of Case/Case Number STATE OF ___________________ SS: COUNTY OF _________________ I hereby swear of affirm that the answers above are true, complete and accurate. I understand that falsification of this document may result in a contempt or 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. (ORC 2921.11) ___________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com Sworn to and subscribed in my presence this ______ day of ______________________, 20____. __________________________________ Notary Public WCJC Form 3.0 Eff. 04/04/11 American LegalNet, Inc. www.FormsWorkFlow.com