GF-150, 05/19 Uniform Child Custody Jurisdiction and Enforcement Act Affidavit 247822.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Enter the name of the county in which you are filing this case. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY In the box to the right, enter the name of the case exactly as it is shown on other papers from the same case. Case Caption: U niform C hild C ustody J urisdiction and E nforcement A ct A ffidavit Case No. Note: Enter case number if one has been assigned; otherwise, l eave case number blank . T he clerk will add this. UNDER OATH I STATE: Enter the name(s) of the child(ren) and their current address. If they currently reside at separate addresses, provide those addresses 1. s name and present address are Name(s): Present Address: See attached Enter any previous addresses at which the child(ren) have lived in the past 5 years. Attach additional sheet, if necessary. 2. The child(ren) have lived in the following places over the last 5 years: See attached Enter the names and current address of each person with whom the child(ren) have lived in the last 5 years. If space is insufficient, or if individual children have lived at different address from others, attach an additional sheet and explain. 3. The name and present address of each person(s) with whom the child(ren) have lived over the last 5 years is Name: Present Address: Time Period: Name: Present Address: Time Period: Name: Present Address: Time Period: Name: Present Address: Time Period: See attached Check yes or no. If yes, enter the name of the court, the case number assigned to it, and the date the court order was entered. Attach an additional sheet, if necessary. 4. I have participated as a party, witness or in any other capacity in any other proceeding concerning the custody, physical placement, or visitation with the child(ren). Yes No If Yes, identify court, case number and date of any determination: See attached Check yes or no. If yes, enter the name of the court, the case number assigned to it, and the nature of the case (that is, what the case was about). 5 . I have information of other proceedings concerning the child(ren) pending in Wisconsin or any other state, including enforcement, domestic violence, protective orders, termination of parental rights and adoption. Yes No If Yes, identify court, case number and nature of proceedings: American LegalNet, Inc. www.FormsWorkFlow.com GF-150, 05/19 Uniform Child Custody Jurisdiction and Enforcement Act Affidavit 247822.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Check yes or no. If yes, enter the name of and address of each person. 6. I know of persons not a party to this proceeding who have physical custody of the child(ren) or claim to have custody, physical placement, or visitation rights with respect to the child(ren). Yes No If Yes, give name and address of each person: 7. I understand that I have a duty to inform the court if I learn in the future of any proceeding concerning the child in Wisconsin or any other state. I declare under the penalty of false swearing that the information I have provided is true and accurate. Signature Print or Type Name Date American LegalNet, Inc. www.FormsWorkFlow.com