Fillable Division: Domestic Relations/Juvenile 1. [ ] I am (Stark County Government)

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Division: Domestic Relations/Juvenile 1. [ ] I am (Stark County Government)

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IN THE COURT OF COMMON PLEAS
FAMILY COURT
STARK COUNTY, OHIO
DECLARATION UNDER UNIFORM CHILD CUSTODY
Case No. ______________________
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
Division: Domestic Relations/Juvenile
I, (full legal name)__________________________________, being sworn according to law, certify that
these proceedings involve the custody of a child, or children and the following statements are true:
1. [ ] I am resting the court to not disclose my address or that of the child(ren). My address is confidential
pursuant to ORC 3127.23(D) and should be placed under seal in that the health, safety, or liberty of myself
and/or the child(ren) would be jeopardized by the disclosure of the identifying information.
2. (Number): Minor Child(ren) are subject to this proceeding as follows:
(Insert the information requested below. The residence information must be given for the last FIVE years.)
a. Child's name Place of birth
Date of birth
Sex
Period of residence
to Present
Address
Confidential
Person child lived with (name & address) Relationship
to
to
to
to
Child's name Place of birth
Date of birth
Sex
Period of residence
to Present
Address
Confidential
Person child lived with (name & address)
Relationship
to
to
to
Child's name
Residence information is the same as given above for child
a. (If NOT the same, provide the information below.)
Place of birth
Date of birth
Sex
Period of residence
to Present
Address
Confidential
Person child lived with (name & address) Relationship
to
to
to
b.
Additional children are listed on Attachment 2e. (Provide requested information for additional children
on an attachment.)
3.
Participation in custody proceeding(s): ( X only one)
____
I HAVE NOT participated as a party, witness, or in any capacity in any other litigation, in this
or any other state, concerning the custody of or visitation (parenting time) with any child
subject to this proceeding.
____
I HAVE participated as a party, witness, or in any capacity in any other litigation, in this or any
other state, concerning the custody of or visitation (parenting time) with any child subject to
this proceeding.
Explain:
a. Name of each child ____________________________________________________________
b. Type of proceeding ____________________________________________________________
c. Court and state ____________________________________________________________
d. Date of court order or judgment (if any): ____________________________________________
4.
Information about custody proceeding(s): ( X only one)
____ I HAVE NO INFORMATION of any proceedings that could affect the current proceeding, including any
proceedings relating to custody, domestic violence or protection orders, dependency, neglect or abuse
allegations, or that a parent or any member of their household has been convicted of a sexually oriented
offense or adoptions concerning any child subject to this proceeding .
____
I HAVE THE FOLLOWING INFORMATION concerning proceedings that could affect the current
proceeding, including any proceedings relating to custody, domestic violence or protection orders,
dependency, neglect or abuse allegations, convictions of a sexually oriented offense or adoptions concerning
any child subject to this proceeding, other than set out in item 3. Explain:
a. Name of each child ____________________________________________________________
b. Name of parent or member of household _____________________________________________
c. Type of proceeding ____________________________________________________________
d. Court and state ____________________________________________________________
e. Date of court order or judgment (if any): ____________________________________________
5.
Persons not a party to this proceeding: ( X only one)
____
I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or claims
to have custody or visitation rights with respect to any child subject to this proceeding.
a. Name and address of person ____________________________________________________
( ) has physical custody
( ) claims custody rights ( ) claims visitation rights
Name of each child ______________________________________________________________
b. Name and address of person ____________________________________________________
( ) has physical custody
( ) claims custody rights
( ) claims visitation rights
Name of each child ______________________________________________________________
c. Name and address of person ____________________________________________________
( ) has physical custody
( ) claims custody rights
( ) claims visitation rights
Name of each child ______________________________________________________________
6.
Knowledge of prior child support proceedings: (X only one)
____
The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this or any
state or territory.
____
The child(ren) described in this affidavit ARE subject to the following existing child support order(s):
a. Name of each child ____________________________________________________________
b. Type of proceeding ____________________________________________________________
c. Court and address ____________________________________________________________
d. Date of court order or judgment (if any): ____________________________________________
e. Amount of child support paid and by whom:__________________________________________
7.
I acknowledge that I have a continuing duty to advise this Court of any custody, visitation,
child support, or guardianship proceeding (including dissolution of marriage, child neglect, or
dependency) concerning the child(ren) in this state or any other state about which information is
obtained during this proceeding.
I certify that a copy of this document was ( X only one) ( )mailed ( )faxed and mailed
( )hand delivered to the person(s) listed below on (date)_________________________________.
Other party or his/her attorney:
Name:__________________________________Address:________________________________
City, State, Zip:__________________________ Fax Number:_____________________________
I understand that I am swearing or affirming under oath to the truthfulness of the statements made in
this affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated:_________________
_____________________________________________
Signature of Party
Printed Name: __________________________________Address:________________________________
City, State, Zip:_________________________________ Phone:_______________Fax:______________
STATE OF OHIO
COUNTY OF ___________
Sworn to or affirmed and signed before me on __________________by______________________
_____________________________________________
Notary Public
____Produced Identification
Type of identification produced _________________________
____Personally known
____
I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has/have
physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this
proceeding: (See next page)
____
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Division: Domestic RelationsJuvenile 1. I am (Stark County Government)

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Completed 18 July 2020

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