Court Form 4

Eff. 7/1/07

IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO

DIVISION OF DOMESTIC RELATIONS

 


 

_____________________________________________                    :

Petitioner

                                                                                                                             :

 

                                                                                                                             :

                                                                v.

                                                                                                                             :

 

_____________________________________________                    :

Respondent


 

     Case No. ______________________________________

 

 

     Judge James W. Conway

 

 

     INFORMATION FOR PARENTING PROCEEDING

     AFFIDAVIT (R.C. 3127.23(A))


 

                                    

NOTE: By law, an affidavit must be filed an served with the first pleading filed by each party in every parenting (custody/visitation) proceeding in this Court, including a Petition for a Domestic Violence Civil Protection Order.  Each party has a continuing duty while this case is pending to inform the Court of any parenting proceeding concerning the child(ren) in any other court in this or any other state.  If more space is needed, attach an additional page.

 

class=Section4>

 

 

I (full legal name)     ______________________________________________, being sworn according to law, certify these cases involve the custody of a child or children and the following statements are true:

 

 

1.     G I am requesting the court to not disclose my current address or that of the child(ren).  My address is confidential pursuant to R.C. 3127.23(D) and should be placed under seal in that the health, safety, or liberty of myself and/or the child(ren) would be jeopardized by the disclosure of the identifying information.

 

2.     (Number):     __________ Minor Child(ren) are subject to this case as follows:

(Insert the information requested below.  The residence information must be given for the last FIVE years.)

 

 

class=Section5>

a. Child’s name

Place of birth

Date of birth

Sex

 

Period of residence

 

GAddress Confidential

Person child lived with (name & address)

Relationship

_______ to present

 

GAddress Confidential

 

 

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

 

b. Child’s name

Place of birth

Date of birth

Sex

 

Period of residence

 

GAddress Confidential

Person child lived with (name & address)

Relationship

_______ to present

 

GAddress Confidential

 

 

_______ to ______

GAddress Confidential

 

 

 

 

 

 

 

class=Section6>

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

 

c. Child’s name

Place of birth

Date of birth

Sex

 

Period of residence

 

GAddress Confidential

Person child lived with (name & address)

Relationship

_______ to present

 

GAddress Confidential

 

 

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

 

d. Child’s name

Place of birth

Date of birth

Sex

 

Period of residence

 

GAddress Confidential

Person child lived with (name & address)

Relationship

_______ to present

 

GAddress Confidential

 

 

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

_______ to ______

GAddress Confidential

 

 

 

 

 

e.  Additional children are listed on Attachment 2(d).  (Provide requested information for additional children on an attachment labeled 2d.)

 

class=Section7>

 

3.             Participation in custody case(s): (only one)

                G             I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitiaion (parenting time) with any child subject to this case.

 

                G             I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitation (parenting time) with any child subject to this case.

                                Explain:

                a.             Name of each child                             _________________________________________________________________

                b.             Type of case                                         __________________________________________________________________

                c.             Court and State                                   __________________________________________________________________

                d.             Date and court order or judgement (if any):          ______________________________________________________

 

4.     Information about custody case(s): (only one)

                G             I HAVE NO INFORMATION of any cases that could affect the current case, any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case.

 

class=Section8>

                G             I HAVE THE FOLLOWING INFORMATION concerning cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations or adoptions concerning any child subject to this case, other than listed in Paragraph 3.

                                Explain:

                a.             Name of each child                             _________________________________________________________________

                b.             Type of case                                         _________________________________________________________________

                c.             Court and State                                   _________________________________________________________________

                d.             Date and court order or judgement (if any):          ______________________________________________________

 

 

 

 

5.             List all of the criminal convictions including guilty pleas for you and the members of your household for the following offenses:

                any criminal offense involving acts that resulted in a child being abused or neglected; any offense that is a violation of R.C.         2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or                 household member at the time of the offense and caused physical harm tot he victim during the commission of the offense.

 

NAME

CASE NUMBER

COURT/STATE/COUNTY

CHARGE

 

 

 

 

 

 

 

 

 

 

 

 

 

6.     Persons not a party to this case: (only one)

                G             I DO NOT KNOW OF ANY PERSON not a party to this case who has physical custody or claims to have custody or visitation rights with respect to any child subject to this case.

 

                G             I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this case:

 

                a.             Name and address of person            __________________________________________________________________

 

                        G     has physical custody                  G     claims custody rights                  G     claims visitation rights

 

                                Name of each child             __________________________________________________________________________

 

                b.             Name and address of person            __________________________________________________________________

 

                        G     has physical custody                  G     claims custody rights                  G     claims visitation rights

 

                                Name of each child             __________________________________________________________________________

 

                c.             Name and address of person            __________________________________________________________________

 

                        G     has physical custody                  G     claims custody rights                  G     claims visitation rights

 

                                Name of each child             __________________________________________________________________________

 

7.                             I understand that I have a continuing duty to advise this Court of any custody, visitation, parenting        time, divorce, dissolution of marriage, separation, neglect, abuse, dependency, guardianship, parentage, termination of parental rights, or protection from domestic violence case concerning the child(ren) in this state or any other state about which information is obtained during this case.

 

 

OATH OF AFFIANT

 

I hereby swear or affirm that the answers above are true, complete and accurate to the best of my knowledge.  I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury under Ohio Revised Code 2921.11.

 

                                ____________________________________________________________

                                AFFIANT

 

                                        Sworn to and subscribed before me on this _______ day of ____________________ , ________________

 

                                ____________________________________________________________

                                NOTARY PUBLIC