Affidavit Concerning Children - State Of Connecticut Superior Court
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1
2AFFIDAVIT CONCERNING
STATE OF CONNECTICUT
CHILDREN
SUPERIOR COURT
COURT OF PROBATE
JD-FM-164 Rev. 6-09
C.G.S. § 46b-115s
INSTRUCTIONS
P.B. § 25-57
Complete form. You must swear that your statement is true and sign it in front of a
Court Use Only
court clerk, a notary public, or an attorney who will also sign and date the affidavit.
AFFACUS
Judicial District of
At (Town)
Probate District name and number
Docket number
Plaintiff/Applicant (Last, first, middle initial)
Defendant/Respondent (Last, first, middle initial)
Information about the past five years for each child affected by this case is required. Provide information below.
If more space is needed, use form JD-FM-164A.
Child's name (First, middle, last)
Date of birth (Month, day, year)
Location
Name(s) and present address(es) of
Relationship
(Town or city, and state, unless
Date(s) of residence
person(s) child lived with
to child
confidential by court order)
(unless confidential)
TO
THE PRESENT
TO
TO
TO
TO
Child's name (First, middle, last)
Date of birth (Month, day, year)
Residence information is same as for child above.
(If not same, provide information)
Name(s) and present address(es) of
Location
Relationship
Date(s) of residence
person(s) child lived with
(Town or city, and state, unless
to child
(unless confidential)
confidential by court order)
TO
THE PRESENT
TO
TO
TO
TO
Check here if additional children are listed on JD-FM-164A.
(Continued...)
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