Affidavit Re Uccjea Information When Prior Order Exists Form Page 2

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_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.
LOCATION OF CHILDREN LAST FIVE YEARS
DATES
Which Children
Lived in Which
with What Parent
Current Address of
To/From
County & State
or Caretaker
that
Parent/Caretaker
I
have
have not participated in any litigation (court cases) concerning the custody,
visitation, parenting time, guardianship, or placement of the child/ren in this or any other state in the last five
years. I have participated in the following litigation:
Name of Court
State
Case Number
Date
Result
I do not know of any other abuse prevention, custody, visitation, parenting time, guardianship, or
placement proceedings involving the child/ren (or any other agency proceeding or court case which could affect
this case) CURRENTLY PENDING in this or any other state
except for :
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(identify agency or court, case number, date filed, and type of proceeding or ruling)
I do not know any person (other than the other parent) who has physical custody of the child/ren or who
claims to have custody, visitation, or parenting time rights
except for : _______________________________
___________________________________________________________________________________________
(list name and address of any such persons)
_______________________________________
_____________________________________________
Father (signature)
Mother (signature)
_______________________________________
_____________________________________________
Name
Name
_______________________________________
_____________________________________________
Street
Street
_______________________________________
_____________________________________________
City/State/Zip
Phone
City/State/Zip
Phone
SUBSCRIBED AND SWORN TO BEFORE ME BY ____________________ this ____ day of _____________,
2007.
_____________________________________________
Notary Public/Clerk of the Court
AFFIDAVIT re UCCJEA INFORMATION WHEN PRIOR ORDER EXISTS
Page 2 --

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