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.

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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.)

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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.)

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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.

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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 _________________________________________________________________