400-00088 226 Affidavit of Child Custody (07/2010) Page 1 of 1 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. In Re: DOB AFFIDAVIT OF CHILD CUSTODY (Use One Form Per Child) 1. My name is 2. My relationship to the child named above is: Parent with legal custody before juvenile case began Legal guardian Custodian Other (describe): 3. During the last five years the child has lived at the following addresses and with the following household members: (Begin with the child's residence just before this Juvenile proceeding started and list all addresses for the past five years. Use an additional page if you need more space.) Address Include street, city and state Dates From when to when Names of all persons residing in the household with the child 4. If the current address of any household member listed in the last column is different from the address listed above, please provide a current address for that person: 5. Please answer the following questions by checking one of the checkboxes. If you answer 221yes222 to any questions, please explain your answer on another page. A. I have participated as a party, witness, or in some other capacity in court proceeding concerning the custody of this child in Vermont or another state: Yes No B. I have information about a custody proceeding concerning this child that is currently pending in a Vermont court or a court in another state: Yes No C. I have knowledge concerning a person who is not a party to these juvenile proceedings who has physical custody of this child or who claims to have custody or visitation rights with respect to this child. Yes No I hereby swear or affirm that the foregoing information is true to the best of my knowledge and belief. Dated Signature Signed and sworn to before me: Notice: During this proceeding, you must inform the Court if you learn of any other custody proceeding concerning the child. Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com