Custody Affidavit {18.P3}

ePC-A-18.P3 (Rev. 11-2008) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE ADOPTION OF Name after adoption CASE NO. CUSTODY AFFIDAVIT [ORC 3127.23] State of Ohio County of Franklin ss: Affiant being first duly sworn, deposes and states: 1. That the present address, the places where the child has lived within the last five years, and the names and present addresses of the person with whom the child has lived during that period are: From: At Current address to With From: At Current address to With From: At Current address to With From: At Current address to With From: At Current address to With From: At Current address to With FRANKLIN COUNTY FORM e18.P3 - CUSTODY AFFIDAVIT American LegalNet, Inc. www.FormsWorkFlow.com Case No. 2. Said affiant (circle one) HAS/HAS NOT participated as a party, witness, or in any other capacity in any other litigation in this or any other state, that concerned the allocation, between the parents of the same child, of potential rights and responsibilities for the care of the child and the designation of the residential parent and legal custodian of the child or that otherwise concerned the custody of the same child. 3. Said affiant (circle one) DOES/DOES NOT HAVE information of any parenting proceeding concerning the child pending in a court of this or another state. 4. Said affiant (circle one) DOES/DOES NOT KNOW of any person who is not a party to the proceeding and has physical custody of the child or claims to be a parent of the child who is designated the residential parent and legal custodial 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. Said affiant (circle one) HAS/HAS NOT been 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 has been determined, in a case 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. 6. Said affiant has a continuing duty to inform the Court of any parenting proceeding concerning the child in this or any other state of which the affiant obtained information during this proceeding. Said affiant has the following knowledge regarding information set forth in paragraphs two (2) through five (5) above: Said affiant states that all of the foregoing statements are true. Affiant/Applicant Sworn to and subscribed before me a Notary Public or Deputy Clerk of the Probate Court on this day of , 20 . Signature page attached Notary Public / Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com