Connecticut > Statewide > Family
Affidavit Concerning Children JD-FM-164 - Connecticut
| Affidavit Concerning Children Form. This is a Connecticut form and can be used in Family Statewide . |
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AFFIDAVIT CONCERNING CHILDREN JD-FM-164 Rev. 6-09 C.G.S. § 46b-115s P.B. § 25-57 STATE OF CONNECTICUT SUPERIOR COURT COURT OF PROBATE INSTRUCTIONS Complete form. You must swear that your statement is true and sign it in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit. At (Town) Probate District name and number www.jud.ct.gov Court Use Only AFFACUS Judicial District of Plaintiff/Applicant (Last, first, middle initial) Docket number 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) Date(s) of residence Location (Town or city, and state, unless confidential by court order) Name(s) and present address(es) of person(s) child lived with (unless confidential) Relationship to child 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) Date(s) of residence Location (Town or city, and state, unless confidential by court order) Name(s) and present address(es) of person(s) child lived with (unless confidential) Relationship to child TO THE PRESENT TO TO TO TO Check here if additional children are listed on JD-FM-164A. (Continued...) American LegalNet, Inc. www.FormsWorkFlow.com 1. (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. 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. Docket number Court location (Including state) 3. Case name Nature of proceeding Case name Nature of proceeding Docket number Court location (Including state) 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 Child's name No Do not know If yes, complete the following: Date of birth (Month, day, year) Signature Sworn to before me (Assistant Clerk/Comm. of Superior Court/Notary Public) Print name of person signing 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. American LegalNet, Inc. www.FormsWorkFlow.com
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