400 - 00834 - UCCJEA Affidavit of Child Custody (01/2018) P age 1 of 1 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. U ni f o r m C h il d C u s t o d y J u r i sd i c t i o n and Enforcement A c t A F FI D A V I T o f CH I L D C U S T O DY I, , h e r eby s t a t e t h a t t he f o l l o w i n g f a c t s are true to the best of my ( Pr i n t N ame) k n o w l e d g e a nd b e l i e f : 1. I a m t h e Pl a i n ti f f in t h is case. D e f e nd a n t i n t h i s cas e . 2. I a m t h e Bi o l o g i c al o r a do p t i v e m o t h e r ; Bi o l o g i c al o r a do p t i v e f a t h e r ; O t h e r : f o r t h e c h i l d ( r e n ) w h o i s/ ar e t h e s u b j ect ( s) o f t h is p r o ce e d i n g . 3. D u r i n g t he l a st f i v e y e a r s, t h e c h i l d r en h av e li v ed a t t he f o l l o wi n g a d d r ess e s w i t h t he fo ll o w ing h o u s e h o l d m e m ber s : ( B e g in w i th t h e c h il d s r e si d e n ce j u st b e f o re t h is c ou rt c a se st a rt e d a n d list a ll addresses for the past five (5) years.) Address Dates From Name of All Persons Residing (Street, City, State) When to When in the Household with the Child to to to U se a n a d d it i o na l pa g e i f y o u n eed m o r e s p a ce. I f c h i l d ren h a ve l i v e d a t d i ffere n t a d dresses fr o m e a c h o t h e r p l e a se i n d i c a te t h e a dd resses f o r e a ch c h i l d . ( A ) If t h e c urre n t a dd r e ss o f a n y h o us e h o l d m e m be r lis t ed i n t he l a st c o l u m n is d i ff e r ent f r o m t he a d d ress l is t e d a b o v e, p l e a s e p r ov i d e a c u r r e nt a d d ress fo r t h a t p ers o n : ( B) P l e a se a ns w e r t h e f o l l o wi n g q u es t i o ns b y c h ec k i ng t h e b o x if t he s t a t e m e n t i s t r u e. If y o ur a ns w er t o a n y o f t he ques t i o n s is e s , p l e a s e e x p l a in y o u r a n s w er o n a n a d d i t i o n a l p a g e. ( i) I h a v e p a r t i c i p a t ed a s a p a r t y , w i t n ess, o r in s om e o t h er w a y i n a c o u r t c a se a b o u t t h e c u st o d y o f t h is c h il d /t h ese c h i l d r en in V e r mo n t o r a n o t h er s t at e . Y es N o ( i i ) I h a v e i n f orm a t i o n a bo u t a c u st o d y ca s e c o n c e r n i n g t h i s c h i l d /t h e s e c h il d r en t h a t is n o w p e n d i n g in a V e r m on t c o u r t o r a c ou r t i n a no t h er st a t e . Y es N o ( i i i) I h a v e kn o w l e d g e a b ou t a p e r s o n w h o i s n o t a p a r t y to t h is case w h o h a s ph y si c al c u st od y o f t h is c h il d /t h ese c h i l d r en o r w h o cl a i m s to h a v e c u s t o d y o r v isi t a t i o n r i g h t s to t h is c h i l d / t h ese c h il d r e n . Y es N o I hereby swear under penalty of perjury that the information above is true and correct to the best of my knowledge and belief. Dated Signature Print Name Signed and sworn to before me: Date: Expiration Date: Signature of Notary: American LegalNet, Inc. www.FormsWorkFlow.com