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Affidavic Uccjea

D.R.L. § 76-h

Form UCCJEA-3

(Affidavit--UCCJEA)

8/2002

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

.............................................................................................

In the Matter of a Proceeding for “ Custody “ Visitation

under the Uniform Child Custody Jurisdiction and

Enforcement Act

Petitioner,

Docket No.

-against -

AFFIDAVIT --

UCCJEA

Respondent.

.............................................................................................

STATE OF NEW YORK )

:ss.:

COUNTY OF

)

I [specify name]:

being duly sworn, deposes and states the following:

1. I “ reside “ am located at [specify address or indicate if ordered to be kept

confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]:

I am the [specify relationship to child(ren); if foster parent, agency, institution or other

relationship, so state]:

and am the “ Petitioner “ Respondent

in the above-entitled proceeding.

2. (Upon information and belief) Each child who is the subject of this proceeding resides

at:

Name

Date of Birth

Address

3. (Upon information and belief) During the last five years each child who is the

Specify address or indicate if ordered to be kept confidential pursuant to Family Court Act

§154-b(2) or Domestic Relations Law §254.

Affidavic Uccjea