Affidavit Concerning Children - State Of Connecticut Superior Court Page 2
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21. (Check one)
I have
I have not been a party or a witness or participated in any other capacity in cases
in Connecticut or any other state concerning custody of or visitation with any child listed in this affidavit.
If yes, identify the name of the court, the court case number and date of determination:
(Check item 2 or 3 below)
2.
I do not know of other civil or criminal proceedings in Connecticut or any other state, now or in the past,
that could affect the current proceeding, including enforcement proceedings and proceedings relating to
family violence, protective orders, termination of parental rights and adoption.
3.
I know of the following civil or criminal proceedings, in Connecticut or any other state, now or in the past,
that could affect the current proceeding, including enforcement proceedings and proceedings relating to
family violence, protective orders, termination of parental rights and adoption.
Case name
Docket number
Court location (Including state)
Nature of proceeding
Case name
Docket number
Court location (Including state)
Nature of proceeding
4. (Check one)
No one except the plaintiff/applicant and defendant/respondent has physical custody
or claims to have custody or visitation rights regarding any child listed here.
The following person(s) has physical custody or claims to have custody or visitation rights
regarding any child listed here:
Name:
Address:
(unless confidential)
5. The mother of the child(ren) named in the Complaint or Application is pregnant.
Yes
No
Do not know
6. A child has been born to the mother named in the Complaint or Application after the filing
of the Complaint or Application.
Yes
No
Do not know
If yes, complete the following:
Child's name
Date of birth (Month, day, year)
Signature
Print name of person signing
Sworn to before me (Assistant Clerk/Comm. of Superior Court/Notary Public)
Date signed
JD-FM-164 (Back) Rev. 6-09
You have an ongoing duty to tell the court about any case
that could affect the current proceeding, in Connecticut
or any other state, if you learn about it during this case.
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