Fillable Connecticut superior court AFFIDAVIT CONCERNING CHILDREN

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Connecticut superior court AFFIDAVIT CONCERNING CHILDREN

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The Connecticut superior court AFFIDAVIT CONCERNING CHILDREN form is 2 pages long and contains:

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  • 14 check-boxes
  • 73 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Connecticut/Department of Administrative Services

BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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sign this form in front of a court clerk, a notary public, or an attorney who will also
sign and date the affidavit.
AFFIDAVIT CONCERNING
CHILDREN
JD-FM-164 Rev. 2-15
C.G.S. § 46b-115s
P.B. § 25-57
STATE OF CONNECTICUT
SUPERIOR COURT
COURT OF PROBATE
www.jud.ct.gov
You must provide information about the past five years for each child affected by this case. Provide the information below.
If you need more space, use form JD-FM-164A.
To The present
To
Place of residence
(Town or city, and state, unless
confidential by court order)
Name(s) and present address(es) of
person(s) child lived with
(unless confidential)
Relationship
to child
To
To
To
Page 1 of 2
Instructions
Date(s) of residence
AFFACUS
Court Use Only
Judicial District of
At (Town)
Probate District name and number Docket number
Plaintiff/Applicant's (Last, first, middle initial) Defendant/Respondent's (Last, first, middle initial)
Child's name (First, middle, last) Date of birth (Month, day, year)
(date)
(date)
(date)
(date)
(date)
Child's name (First, middle, last) Date of birth (Month, day, year)
Residence information is same as for child above.
(If not same, provide information)
Check here if additional children are listed on JD-FM-164A.
To The present
To
Place of residence
(Town or city, and state, unless
confidential by court order)
Name(s) and present address(es) of
person(s) child lived with
(unless confidential)
Relationship
to child
To
To
To
Date(s) of residence
(date)
(date) (date)
(date) (date)
(date) (date)
(date) (date)
From
From
From
From
From
From
From
From
From
From
(date)
(date)
(date)
(date)
*AFFACUS*
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5. The mother of the child(ren) named in the Complaint or Application is pregnant.
6. A child has been born to the mother named in the Complaint or Application after the filing of the Complaint or Application.
No one except the plaintiff/applicant and defendant/respondent has physical custody
or claims to have custody or visitation rights regarding any child listed here.
The following person(s) has physical custody or claims to have custody or visitation rights
regarding any child listed here:
I do not know of other civil or criminal cases in Connecticut or another state, now or in the past, that could affect the
current case, including enforcement cases and family violence, protective order, termination of parental rights and
adoption cases.
1. (Check one)
been involved as a party or a witness or in any other capacity in a case
or cases in Connecticut or in another state concerning custody of or visitation with any child listed in this affidavit. If you
checked "I have," give the name of the court, the court case number and the date of the decision in the case or cases:
Signature
Sworn to before me (Assistant Clerk/Commissioner of Superior Court/Notary Public)
JD-FM-164 Rev. 2-15
You must tell the court about any case in Connecticut or
another state that could affect this case, if you learn about
it during this case.
(Check item 2 or 3 below)
4. (Check one)
I know of the following civil or criminal cases, in Connecticut or another state, now or in the past, that could affect the
current case, including enforcement cases and family violence, protective order, termination of parental rights and
adoption cases.
(unless confidential)
I have I have not
2.
3.
Case name
Docket number
Court location (Including state)
Nature of proceeding
Case name Docket number
Court location (Including state)
Nature of proceeding
Name:
Address:
Yes No Do not know
Yes No Do not know If yes, fill in the following:
Child's name
Date of birth (Month, day, year)
Print name of person signing
Date signed
Page 2 of 2
ADA NOTICE
The Judicial Branch of the State of
Connecticut complies with the
Americans with Disabilities Act (ADA). If
you need a reasonable accommodation
in accordance with the ADA, contact a
court clerk or an ADA contact person
listed at www.jud.ct.gov/ADA.
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Connecticut superior court AFFIDAVIT CONCERNING CHILDREN

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Completed 2 April 2020

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