Addendum To Affidavit Concerning Children {JD-FM-164A}

ADDENDUM TO AFFIDAVIT CONCERNING CHILDREN JD-FM-164A Rev. 11-14 C.G.S. § 46b-115S, P.B. § 25-57 Child's name (First, middle, last) STATE OF CONNECTICUT SUPERIOR COURT (Use this form to list additional children to form JD-FM-164) Date of birth (Month, day, year) Docket number Residence information is same as for previous child (If not same, provide information) Relationship to child Date(s) of residence Location (Town or city, and state, unless confidential) Name(s) and present address(es) of person(s) child lived with (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 previous child (If not same, provide information) Relationship to child Date(s) of residence Location (Town or city, and state, unless confidential) Name(s) and present address(es) of person(s) child lived with (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 previous child (If not same, provide information) Relationship to child Date(s) of residence Location (Town or city, and state, unless confidential) Name(s) and present address(es) of person(s) child lived with (unless confidential) to the present to to to to (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com Child's name (First, middle, last) Date of birth (Month, day, year) Residence information is same as for previous child (If not same, provide information) Relationship to child Date(s) of residence Location (Town or city, and state, unless confidential) Name(s) and present address(es) of person(s) child lived with (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 previous child (If not same, provide information) Relationship to child Date(s) of residence Location (Town or city, and state, unless confidential) Name(s) and present address(es) of person(s) child lived with (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 previous child (If not same, provide information) Relationship to child Date(s) of residence Location (Town or city, and state, unless confidential) Name(s) and present address(es) of person(s) child lived with (unless confidential) to the present to to to to The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/ American LegalNet, Inc. www.FormsWorkFlow.com JD-FM-164A Rev. 11-14 (Page 2 of 2)