DR-9 (4/01)SUP. CT. FORM 10.01-F AFCC IN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS CASE NO. Plaintiff/PetitionerJUDGE:CROSS / KING VS. / ANDINFORMATION FOR PARENTING Defendant/Petitioner/RespondentPROCEEDING AFFIDAVIT (R.C. 3109.27)NOTE: By law, this affidavit must be filed and served with the first pleading filed by each party in every parenting proceeding in this court, including a Petition for Domestic Violence Civil Protection Order. Each party has a continuing duty while this case is pending to inform the court of any parenting proceeding concerning the child(ren) in any other court in this or any other state. If more space is needed, attach an additional page.Affiant, , being duly cautioned and sworn states as follows: 1.The name, birth date, and Social Security Number (if any) of each child whose custody/visitation is at issue in this case is: Name of ChildSocial Security Number Date of Birth2.The present home address of each child is: Name of ChildAddress 3.The child currently resides with what adult(s)? Name of ChildName of Adult(s) 4.All other places and dates where each child has lived during the last FIVE (5) years, and the names of all adult(s) with whom they lived at each address, are as follows: Name of ChildDate (from -to) AddressName of Adult(s)5.The name(s) and current addresses of all adults listed above are: Name of AdultAddress 12002 © American LegalNet, Inc.6.Do you know of any litigation anywhere, past or present, which concerns the custody, parenting time/visitation, or care of the child(ren)? YES NO (Check one)7.If the answer to #6 is yes , state any other information you have about any parenting proceeding concerning the child(ren) in a court of this state or any other state. Include the case number, the name of the court, the address of the court, and the year. Case NumberName of CourtAddress of CourtYear of Case 8.State the name and address of any person who is not a party to this proceeding: (A) who has physical possession of the child(ren), or (B) who claims to be a parent of the child(ren) and is either the residential parent and legal custodian, or has parenting time/visitation rights with the child, or (C) who is a person other than a parent of the child(ren) who has custody or visitation rights. NameState reason A, B, or C from above Address9.Are you now, or have you ever been, a party to any civil or criminal case or any investigation concerning child abuse, child neglect, or domestic violence? If so, state each court, case name, case number, date, as well as the nature and outcome of the case. Case NumberName of CourtDateNature and Outcome Case Name10.Do you have any domestic violence protection orders or any other restraining orders issued against you, or on your behalf against any other person? If so, state each court, case name, case number, and date, as well as the nature and outcome of the case. Case NumberCase NameName of CourtDateNature and Outcome OATH OF AFFIANTI hereby swear or affirm that the answers above are true, complete and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (R.C. 2921.11) SIGNATURE OF AFFIANTDATESworn to and subscribed before me this day of , .NOTARY PUBLIC My commission expires .22002 © American LegalNet, Inc.
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