IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _________________ In the Matter of ‘ the Marriage of: ________________________________, Petitioner, and ________________________________, Respondent. ) ) ) ) ) ) ) ) Case No. ______________________ ‘ PETITIONER’S ‘ RESPONDENT’S AFFIDAVIT RESPONDING TO MOTION TO MODIFY JUDGMENT RE: ‘ CUSTODY ‘ PARENTING TIME ‘ CHILD SUPPORT [ORS 107.174] STATE OF ______________________ ) ) ss. County of _______________________ ) I, ‘ Petitioner ‘ Respondent, being first duly sworn, say that the following is true: I make this affidavit to respond to the motion to modify that has been filed. 1. ‘ I disagree with the following request(s) made by the other party to: a. ‘ Change custody of the minor child/ren because: b. ‘ Change the current court-ordered parenting time because: Page 1 of 4, ‘ PETITIONER’S ‘ RESPONDENT’S AFFIDAVIT RESPONDING MOTION TO MODIFY JUDGMENT (ORS 107.174) Modification-4B: Response4BVer04.wpd (12/03) American LegalNet, Inc. www.USCourtForms.com c. ‘ Terminate ‘ Petitioner’s ‘ Respondent’s child support obligation due to the requested change in custody because: d. ‘ Require ‘ Petitioner ‘ Respondent to pay child support in the amount of $ per month beginning e. , 20 , because: ‘ Require ‘ Petitioner ‘ Respondent to obtain and maintain life insurance for the benefit of the parties’ child/ren throughout the period of the support obligation because: f. ‘Require ‘ Petitioner ‘ Respondent to name the child/ren as beneficiaries of any health, accident, dental, orthodontic, and optical insurance plan available through that parent’s employment, group, or union, or ‘ that ‘ Petitioner ‘ Respondent pay ______% of the uninsured costs incurred by the child/ren including costs for prescriptions because: g. That court costs and service fees be paid by ‘ Petitioner ‘ Respondent ‘ Other ‘ Each party responsible for paying his or her own court costs and services fees because: Page 2 of 4, ‘ PETITIONER’S ‘ RESPONDENT’S AFFIDAVIT RESPONDING MOTION TO MODIFY JUDGMENT (ORS 107.174) Modification-4B: Response4BVer04.wpd (12/03) American LegalNet, Inc. www.USCourtForms.com h. Other: because: 2. Information Required by the Uniform Child Custody Jurisdiction and Enforcement Act. List the places where the minor child/ren of the parties have lived in the last five years and the names of the people they lived with at that time. Dates County, State Parent(s)/Caretaker Current Address/ Contact Address of Parent/Caretaker Which Children ‘ Additional page attached; see section labeled “UCCJEA Information Continued”. I ‘ have ‘ have not participated in any litigation concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following litigation: Name of Court State Case No. Date Result I do not know of any other domestic violence, custody, visitation, parenting time or placement proceeding involving the child/ren, or of any other agency proceeding or court case which could affect this case, previously filed or currently pending in this or any other state ‘ except for: (identify agency or court, case number, date filed, and kind of proceeding) Page 3 of 4, ‘ PETITIONER’S ‘ RESPONDENT’S AFFIDAVIT RESPONDING MOTION TO MODIFY JUDGMENT (ORS 107.174) Modification-4B: Response4BVer04.wpd (12/03) American LegalNet, Inc. www.USCourtForms.com I do not know any person other than petitioner who has physical custody of the child/ren or who claims to have custody, visitation or parenting time rights ‘ except for: (list name and address) Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: ‘ I selected this document for myself and I completed it without paid assistance. ‘ I paid or will pay money to ______________________________ for assistance in preparing this form. _____________________________________________________________________________________ ‘ Petitioner ‘ Respondent, Signature Print Name _____________________________________________________________________________________ Address or Contact Address City, State, Zip Telephone or Contact Telephone SIGNED AND SWORN to before me this ___________ day of _______________, 20 _____. ____________________________________ Notary Public for ____________/Court Clerk My Commission Expires: _______________ I certify that this is a true copy. ____________________________________ ‘ Petitioner ‘ Respondent, Signature Page 4 of 4, ‘ PETITIONER’S ‘ RESPONDENT’S AFFIDAVIT RESPONDING MOTION TO MODIFY JUDGMENT (ORS 107.174) Modification-4B: Response4BVer04.wpd (12/03) American LegalNet, Inc. www.USCourtForms.com