Custody Affidavit Form - Probate Court Of Wayne County, Ohio
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1
2PROBATE COURT OF WAYNE COUNTY, OHIO
LATECIA E. WILES, JUDGE
IN THE MATTER OF THE ADOPTION OF:
_______________________________
Name after adoption
CASE NO.:
___________________
CUSTODY AFFIDAVIT
[ORC 3127.23]
State of ______________,
County of _____________ ss:
Affiant being first duly sworn, deposes and states:
1.
That the present address, the places where the child has lived within the last five
years, and the names and present addresses of the person with whom the child lived during
that period are:
From: ____________ to ____________, with __________________________________, at
________________________________; Current Address: ____________________________
From: ____________ to ____________, with __________________________________, at
________________________________; Current Address: ____________________________
From: ____________ to ____________, with __________________________________, at
________________________________; Current Address: ____________________________
From: ____________ to ____________, with __________________________________, at
________________________________; Current Address: ____________________________
From: ____________ to ____________, with __________________________________, at
________________________________; Current Address: ____________________________
From: ____________ to ____________, with __________________________________, at
________________________________; Current Address: ____________________________
18.0.2 WC Probate Form Custody Affidavit (adoption), revised 1/6/15
Page 1 of 2
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