Mandatory Uccjea Affidavit For Child Custody/visitation Form
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1________________________________
15th JUDICIAL DISTRICT COURT
VERSUS
DOCKET NO.: __________________________
________________________________
_____________________ PARISH, LOUISIANA
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * ** * * * * * *
MANDATORY UCCJEA AFFIDAVIT FOR CHILD CUSTODY/VISITATION
I, (full name) _____________________, swear that the following statements are true:
Name, birth date and sex of each child who is involved in this court case only:
Name: ______________________ Date of Birth: ________________ Male / Female
Name: ______________________ Date of Birth: ________________ Male / Female
Name: ______________________ Date of Birth: ________________ Male / Female
Name: ______________________ Date of Birth: ________________ Male / Female
Name: ______________________ Date of Birth: ________________ Male / Female
Where are the child(ren) living today? ______________________________________________
(2)
List all parishes/counties & states where the child(ren) have lived in the past five (5) years:
Parish/County:
State or Country:
When child(ren) lived there (dates):
__________________
_____________________
_________________________
__________________
_____________________
_________________________
__________________
_____________________
_________________________
__________________
_____________________
_________________________
(3)
List all persons other than you with whom the child(ren) have lived in the past five (5) years:
Name:
Address:
Relationship:
_____________________
______________________
________________________
_____________________
______________________
________________________
_____________________
______________________
________________________
(4)
Have the child(ren) ever been the subject of any of the following kinds of cases? If yes, check below:
Divorce/Separation
_____
Juvenile Court
______
Custody/Visitation
_____
Child Protection
______
Child Support
_____
Abuse/Neglect
______
Paternity
_____
Parental Rights Termination
______
Protective Order
_____
Adoption
______
Restraining Order
_____
Other
______
(5)
If you checked yes to # 3 above, answer the following:
A. Name of Child(ren):___________________________________________________________
B. Type of Proceeding (custody, visitation, paternity, OCS, protective order, etc.)
___________________________________________________________________________
C. Court, Parish/County & State:_____________________Docket No.:____________________
D. Case is still open/on-going: _______
Case is not open/on-going: _______
(6)
If you know of any person NOT a party to this proceeding who has physical custody or claims to have custody/visitation rights
to a child(ren) listed above, please provide the following:
Name: ________________________________________________________________________
Address of Person: _______________________________________________________________
I HEREBY ACKNOWLEDGE that I have a continuing duty to advise this Court of any proceeding concerning the child(ren)
in this state or any other state which may affect the outcome of this proceeding. I further understand that if I knowingly
swear or affirm falsely that the punishment may include fines and imprisonment.
Sworn to and Subscribed before me on this
___________________________________________
_____ day of_______, 20____.
(Sign Your Name)
___________________________________________
(Print Your Name)
___________________________________
___________________________________________
Notary Public
(Your Address)
___________________________________________
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