Affidavit In Compliance With 3127.23 Ohio Revised Code - Hamilton County Juvenile Court Page 2
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1
2(
)
6.
The petitioner(s)
knows, know, does not know,
do not know
of any other person or persons having physical
custody or claims to have custody or visitation rights of this child or these children, who is not included as a party in
this proceeding. Please list the name, complete address and relationship to the child or children:
(
)
7.
The child or children
was, was not, were, were not
the subject of any divorce proceedings involving the
biological parents in this or any other State. If Affirmative, describe where, when and the ruling concerning custody
and visitation.
8.
The biological parents are:
Currently Married
Separated but Legally Married
Divorced
Never Married
9.
A social service agency such as Children’s Protective Service, Catholic Social Services or the Department of Jobs and
, (
)
Family Services
is, is not
currently involved with the welfare of these child or these children. Please explain
affirmative answer:
(
)
10.
The petitioner(s)
has a, has no,
have a,
have no
history of charges, conviction, adjudication, guilty plea or
been determined to be the perpetrator of any criminal offense that involved an act that resulted in a child being
abandoned, abused or neglected. Please provide details of affirmative answer:
11.
The petitioner(s) ( has
has not
have
have not) included a separate sworn affidavit or pleading concerning the
health, safety or liberty of the petitioner(s), child or children being jeopardized by the disclosure of identifying
information as outlined in section D of ORC3127.23.
Sworn to before me and subscribed in my presence this
day of
20
.
Petitioner (s)
Notary Public
Child Custody Affidavit - Page 2 of 2
Form 551B - Revised 8/2006
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