CASE NAME:
1. The name and present address of each child (under 18) in this case is:
2. The addresses where the child(ren) has/have lived within the last 5 years are:
3. The name(s) and present address(es) of custodians with whom the child(ren) has/have lived within the last 5 years are:
4. I do not know of, and have not participated (as a party, witness, or in any other capacity) in any other court decision, order, or
proceeding (including divorce, separate maintenance, separation, neglect, abuse, dependency, guardianship, paternity,
termination of parental rights, and protection from domestic violence) concerning the custody or parenting time of the child(ren),
in this state or any other state, except: Specify case name and number, court name and address, and date of child custody determination, if one.
5. I do not know of any pending proceeding that could affect the current child custody proceeding, including a proceeding for
enforcement or a proceeding relating to domestic violence, a protective order, termination of parental rights, or adoption, in this
state or any other state, except: Specify case name and number, court name and address, and nature of the proceeding.
That proceeding is continuing. has been stayed by the court.
Temporary action by this court is necessary to protect the child(ren) because the child(ren) has/have been subjected to or
threatened with mistreatment or abuse or is/are otherwise neglected or dependent. Attach explanation.
6. I do not know of any person who is not already a party to this proceeding who has physical custody of, or who claims rights of
legal or physical custody of, or parenting time with, the child(ren), except: State name(s) and address(es) of each person.
7. The child(ren)'s "home state" is . See back for definition of "home state."
8. I state that a party's or child's health, safety, or liberty would be put at risk by the disclosure of this identifying information.
I have filled this form out completely, and I acknowledge a continuing duty to advise this court of any proceeding in this state or
any other state that could affect the current child-custody proceeding.
Subscribed and sworn to before me on , County, Michigan.
My commission expires: Signature:
Notary public, State of Michigan, County of
MC 416 (3/08) UNIFORM CHILD CUSTODY JURISDICTION ENFORCEMENT ACT AFFIDAVIT
MCL 722.1206, MCL 722.1209
Approved, SCAO
STATE OF MICHIGAN
JUDICIAL CIRCUIT
PROBATE COURT
COUNTY
CASE NO.
UNIFORM CHILD CUSTODY JURISDICTION
ENFORCEMENT ACT AFFIDAVIT
Court address Court telephone no.
Original - Court
1st copy - FOC (if applicable)
2nd copy - Defendant/Respondent
3rd copy - Plaintiff/Petitioner
Address of affiant
Name of affiant (type or print)
Signature of affiant
Date
Date
