AFFIDAVIT (Uniform Child Custody Jurisdiction and Enforcement Act) COMMONWEALTH OF VIRGINIA Va. Code § 20-146.20 ....................................................................................................................................................................... Case No. ....................................................................................... [ ] Circuit Court [ ] Juvenile and Domestic Relations District Court In re: .................................................................................................................................................................................................................................................................... JUVENILE .............................................................................................................................. v. ............................................................................................................................... I, ................................................................................................................................... the undersigned affiant, state the following information under oath: [ ] Certain information has been omitted from this form and submitted under seal because I allege that the health, safety or liberty of a party or child would be jeopardized by disclosure. Another party may request that a hearing be held to determine whether this information should be disclosed. 1. The child presently resides at: .......................................................................................................................................................................................................... ADDRESS The child commenced residing there on 2. 3. ...................................................................................... DATE and has resided there continuously to this date. The other places where and persons with whom this child has lived during the last five (5) years : (please complete reverse side). I [ ] have [ ] have not participated, either as a party, witness, or in any other capacity in any other litigation (court proceeding) concerning custody of or visitation with this child, in any State or foreign country. If yes, complete below: a. b. c. d. Name of Court and State or foreign country in which litigation occurred: When did the litigation occur: ............................................................................................................ .................................................................................................................................................................................................. ............................................................................................................................................................................... What was the outcome of the litigation: Attach a copy of all pleadings and Orders filed in this litigation. 4. I [ ] do [ ] do not have knowledge or information of any proceeding that could affect this proceeding, including but not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective orders, abuse and neglect, termination of parental rights and adoptions, which is pending in a court of this or any other State or foreign country. If yes, complete below: a. Name of Court and State or foreign country in which proceeding is pending: ..................................................................................................... ................................................................................................................................................................................................................................................................ b. 5. Attach a copy of all pleadings filed in the litigation. I [ ] do [ ] do not know of any person who is not already named as a party in this proceeding who has physical custody of this child or who claims to have custody or visitation rights with respect to child. If yes: a. b. c. Name and address of person: .................................................................................................................................................................................................... Does this person have physical custody of the child? [ ] Yes [ ] No ................................................................................. State why you believe this person claims to have custody/visitation rights to the child: ..................................................................................................................................................................................................................................................................... 6. I understand that I have an obligation to promptly inform this court if I later become aware of any other proceedings, including but not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective orders, abuse and neglect, termination of parental rights and adoptions, either in this or any other State or foreign country that could affect the current proceeding. ________________________________________________ SIGNATURE OF AFFIANT Subscribed and sworn to before me on Title: ................................................. DATE ............................................................................................................ ____________________________________________________________ SIGNATURE FOR NOTARY PUBLIC'S USE ONLY: State of ................................................................................................ [ ] City [ ] County of ................................................................................................ Acknowledged, subscribed and sworn to before me this ......................................................................................... NOTARY REGISTRATION NUMBER ...................... day of .................................................................................... , 20 ............... ________________________________________________________ NOTARY PUBLIC (My commission expires: ................................) FORM DC-620 (FRONT) 05/08 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT (continued) Question #2: Places where and persons with whom the child h