PROBATE COURT OF BUTLER COUNTY, OHIOIN THE MATTER OF THE PLACEMENT OF(Current name of child) CASE NO.AFFIDAVIT[R.C. 3109.27]State of Ohio, County ofs.s.Affiant being first duly sworn, deposes and says: 1.That the child's present address, the places where the child has lived within the last five years, and the names and addresses of the person(s) with whom the child has lived during that period are:2.That affiant has (not) participated as a party, witness, or in any other capacity in any litigation concerning the allocation, between the parents of the same child, of parental rights and responsibilities for the care of the child and the designation of the residential parent and legal custodian of the child that otherwise concerned the custody of the same child. 3.That affiant has (no) information of any parenting proceeding concerning the child pending in a court of this or any other state. 4.That affiant has (no) knowledge of any person who is not a party to the proceedings and has physical custody of the child or claims to be a parent of the child who is designated the residential parent and legal custodian of the child or to have visitation rights with respect to the child or to be a person other than a parent of the child who has custody or visitation rights with respect to the child. 5.That affiant has (not) been previously convicted of or pleaded guilty to any criminal offense involving any act that resulted in a child being an abused child or a neglected child or previously been determined, in a case in which a child has been adjudicated an abused child or a neglected child, to be the perpetrator of the abusive or neglectful act that was the basis of the adjudication. If 2, 3, 4 or 5 is answered in the affirmative, and the space afforded is insufficient for full explanation, please attach and incorporate herein any necessary information. Affiant realizes that (s)he has a continuing duty to inform the Court of any parenting proceeding concerning the child in this or any other state of which affiant obtains information during the pendency of this proceeding.Signature of AffiantSworn to before me and subscribed in my presence this.,day ofNotary Public3/98BCPC FORM 308 -AFFIDAVIT2001 © American LegalNet, Inc.
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