400-00088 – Affidavit of Child Custody (07/2010) Page 1 of 1
In Re: DOB
AFFIDAVIT OF CHILD CUSTODY
(Use One Form Per Child)
1. My name is
___________________________________________
2. My relationship to the child named above is:
☐ Parent with legal custody before juvenile case began
☐ Legal guardian
☐ Custodian
☐ Other (describe): _______________________________________
3. During the last five years the child has lived at the following addresses and with the following
household members: (Begin with the child's residence just before this Juvenile proceeding started and list all addresses
for the past five years. Use an additional page if you need more space.)
Address
Include street, city and state
Names of all persons residing in
the household with the child
4. If the current address of any household member listed in the last column is different from the
address listed above, please provide a current address for that person:
_________________________________________________________________________________
_________________________________________________________________________________
5. Please answer the following questions by checking one of the checkboxes. If you answer ‘yes’ to any
questions, please explain your answer on another page.
A. I have participated as a party, witness, or in some other capacity in court proceeding concerning
the custody of this child in Vermont or another state: ☐ Yes ☐ No
B. I have information about a custody proceeding concerning this child that is currently pending in a
Vermont court or a court in another state: ☐ Yes ☐ No
C. I have knowledge concerning a person who is not a party to these juvenile proceedings who has
physical custody of this child or who claims to have custody or visitation rights with respect to this
child. ☐ Yes ☐ No
I hereby swear or affirm that the foregoing information is true to the best of my knowledge and belief.
________________________________________ ________________________________________
Dated Signature
Signed and sworn to before me:
Notice: During this proceeding, you must inform the Court if you learn of any other custody proceeding
concerning the child.
Date Signature of Notary Public Expiration Date
