Rule text
IN THE COURT OF COMMON PLEAS DIVISION COUNTY, OHIO Case No. Plaintiff/Petitioner 1 Judge vs./and Magistrate Defendant/Petitioner 2/Respondent Instructions: Check local court rules to determine when this form must be filed. By law, this affidavit must be filed and served with any Complaint, Petition or Motion regarding the allocation of parental rights and responsibilities, parenting time, custody, or visitation. 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, add additional pages. PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23(A)) Affidavit of (Print Name) ONLY CHECK THE FOLLOWING BOX IF YOU BELIEVE THAT THE HEALTH, SAFETY, OR LIBERTY OF YOURSELF OR YOUR CHILD(REN) WOULD BE JEOPARDIZED BY THE DISCLOSURE OF YOUR ADDRESS OR IDENTIFYING INFORMATION. YOU ACKNOWLEDGE THAT THE COURT MAY CONDUCT A HEARING REGARDING THE BASIS FOR YOUR REQUEST. Pursuant to R.C. 3127.23(D), I allege that my health, safety, or liberty or that of my child(ren) would be jeopardized by the disclosure of identifying information to my spouse or the public. Therefore, I request that my address be placed under seal. I have marked the corresponding box next to each address I am requesting to be sealed. 1. (Number): _______ Minor child(ren) is/are subject to this case as follows: Insert the information requested below for all minor or dependent children of the parties. You must list the residences for all places where the children have lived for the last FIVE years. a. Child’s name _____________________________________________ Place of birth ________________________ Date of birth ________________________ Sex M F Date of residence Address Confidential Person child lived with (name and address) Relationship ___________________________________ ___________________________________ ___________________ ________________ to present ___________________________________ ___________________________________ ___________________ to _________________ ________________
___________________________________ ___________________________________ ___________________ to _________________ ________________ ___________________ to _________________ ___________________________________ ___________________________________ ________________ b. Child’s name _____________________________________________ Place of birth ________________________ Date of birth ________________________ Sex M F Check this box if the information below is the same as in Section 1(a). Skip to the next question. Date of residence Address Confidential Person child lived with (name and address) Relationship ___________________________________ ___________________________________ ___________________ ________________ to present ___________________________________ ___________________________________ ___________________ to _________________ ________________ ___________________________________ ___________________________________ ___________________ to _________________ ________________ ___________________________________ ___________________________________ ___________________ to _________________ ________________ c. Child’s name _____________________________________________ Place of birth ________________________ Date of birth ________________________ Sex M F Check this box if the information below is the same as in Section 1(a). Skip to the next question. Date of residence Address Confidential Person child lived with (name and address) Relationship ___________________________________ ___________________________________ ___________________ ________________ to present ___________________________________ ___________________________________ ___________________ to _________________ ________________ ___________________________________ ___________________________________ ___________________ to _________________ ________________ ___________________________________ ___________________________________ ___________________ to _________________ ________________ d. Additional children are listed on Attachment 1(d). (Provide requested information for additional children on an attachment labeled 1(d).)
2. Participation in custody case(s): (Check only one box) I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitation (parenting time), with any child subject to this case. I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitation (parenting time), with any child subject to this case. Explain: a. Name of each child: __________________________________________________________________ b. Type of case: _______________________________________________________________________ c. Court and State: ____________________________________________________________________ d. Date and court order or judgment (if any): ________________________________________________ 3. Information about custody case(s): (Check only one box) I HAVE NO INFORMATION of any cases that could affect the current case, including any cases relating to custody; domestic violence or protection orders; dependency, neglect, or abuse allegations; or adoptions concerning any child subject to this case. I HAVE THE FOLLOWING INFORMATION concerning cases that could affect the current case, including any cases relating to custody; domestic violence or protection orders; dependency, neglect, or abuse allegations; or adoptions concerning a child subject to this case, other than listed in Paragraph 2. Explain: a. Name of each child: _________________________________________________________________ b. Type of case: ______________________________________________________________________ c. Court and State: ____________________________________________________________________ d. Date and court order or judgment (if any): ________________________________________________ 4. Information about criminal convictions: List all of the criminal convictions, including guilty pleas, for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any domestic violence offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm to the victim during the commission of the offense. NAME CASE NUMBER COURT/COUNTY/STATE CHARGE 5. Persons not a party to this case: (Check only one box) I DO NOT KNOW OF ANY PERSON not a party to this case who has physical custody or claims to have custody or visitation rights with respect to any child subject to this case. I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this case.
a. Name/Address of Person: _________________________________________________________ has physical custody claims custody rights claims visitation rights Name of each child: ______________________________________________________________ b. Name/Address of Person: _________________________________________________________ has physical custody claims custody rights claims visitation rights Name of each child: ______________________________________________________________ c. Name/Address of Person: _________________________________________________________ has physical custody claims custody rights claims visitation rights Name of each child: ______________________________________________________________ 6. I understand that I have a continuing duty to advise this Court of any custody, visitation, parenting time, divorce, dissolution of marriage, separation, neglect, abuse, dependency, guardianship, parentage, termination of parental rights, or protection order from domestic violence case concerning the children about whom information is obtained during this case. OATH OR AFFIRMATION (Do not sign until Notary Public is present) I, (print name), swear or affirm that I have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature STATE OF _____________________)) SS COUNTY OF ___________________) Sworn to or affirmed before me by _________________________this ______day of ______________,______. ___________________________________ Signature of Notary Public ___________________________________ Printed Name of Notary Public Commission Expiration Date: ___________ (Affix seal here)