Custody Affidavit Form - Probate Court Of Wayne County, Ohio Page 2
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22.
Said affiant (check one)
HAS
HAS NOT participated as a party, witness, or in
any other capacity in any other litigation in this or any other state, that concerned the
allocation, between the parents of the same child, of potential rights and responsibilities for
the care of the child and the designation of the residential parent and legal custodian of the
child or that otherwise concerned the custody of the same child.
3.
Said affiant (check one)
DOES
DOES NOT HAVE information of any
parenting proceeding concerning the child pending in a court of this or another state.
4.
Said affiant (check one)
DOES
DOES NOT KNOW of any person who is not a
party to the proceeding and has physical custody of the child or claims to be a parent of
the child who is designated the residential parent and legal custodial of the child or to
have visitation rights with respect to the child or to be a person other than a parent of the
child who has custody or visitation rights with respect to the child.
5.
Said affiant (check one)
HAS
HAS NOT been convicted of or pleaded guilty to
any criminal offense involving any act that resulted in a child being an abused child or a
neglected child or previously has been determined, in a case which a child has been
adjudicated an abused child or a neglected child, to be the perpetrator of the abusive or
neglectful act that was the basis of the adjudication.
6.
Said affiant has a continuing duty to inform the Court of any parenting proceeding
concerning the child in this or any other state of which the affiant obtained information
during this proceeding.
Said affiant has the following knowledge regarding information set forth in paragraphs two
(2) through five (5) above:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Said affiant states that all of the foregoing statements are true.
__________________________________
Affiant/Applicant
Sworn to and subscribed before me a Notary Public or Deputy Clerk of the Probate
Court on this __________ day of ____________________, 20____.
___________________________________
Notary Public/Deputy Clerk
18.0.2 WC Probate Form Custody Affidavit (adoption), revised 1/6/15
Page 2 of 2
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