Rsa 458-A, Uniform Child Custody Jurisdiction And Enforcement Act Affidavit Page 2
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1
2Case Name:
Case Number:
UCCJEA AFFIDAVIT
4. Check one of the following:
I have not participated in any court case(s) concerning the custody, visitation, parenting time
or placement of the child/ren in this or any other state.
OR
I have participated in court case(s) concerning the custody, visitation, parenting time or
placement of the child/ren in this or any other state. I have participated in the following:
Name of Court
State
Case No.
Date of Court Order
5. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic
relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and
responsibilities, termination of parental rights, adoption, juvenile, or other proceedings in any court in
any state affecting any children named in this petition or parents of those children?
Yes
No
If yes, complete the following:
Name of Court
State
Case No.
Type of Court Case
6. Optional:
I am alleging, under oath, that my or my child/ren’s health, safety, or liberty would be
jeopardized by the disclosure of identifying information set forth in this Affidavit. To support my
allegation, I state as follows:
Note: In domestic violence actions under RSA 173-B, the whereabouts of the plaintiff shall not be
released except by court order.
I acknowledge that I have a continuing duty to inform the court of any court action in this or
any other state that could affect the child/ren in this case.
I swear or affirm that the foregoing information is true and correct to the best of my knowledge.
Date
Signature of Person Completing Affidavit
Printed Name of Person Completing Affidavit
State of
, County of
This instrument was acknowledged before me on
by
Date
Person Signing Above
My Commission Expires
Affix Seal, if any
Signature of Notarial Officer / Title
NHJB-2660-DFP (12/01/2010)
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