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THE STATE OF NEW HAMPSHIRE (State of New Hampshire)

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U.S.A. forms for State of New Hampshire

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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
UNIFORM CHILD CUSTODY JURISDICTION
AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT
RSA 458-A
It is important that you answer these questions with as much detail and accuracy as possible. Lack of
adequate information could significantly delay orders being issued in your case.
There are several situations that might result in New Hampshire exercising jurisdiction over child/ren.
The continuous presence of the child/ren in New Hampshire for six (6) months is not the only basis
for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a
temporary basis.
1. List minor children born to or adopted by the parties:
Name Date of Birth Current Address
2 List the places where the minor child/ren of the parties has/have lived in the last five (5) years
and the names of the people they lived with at that time, if you know. Start with where the child lives
now and work backward in time.
Dates
From/To
Town/City, State Parent(s)/Caretaker Current Address/Contact
Address of Parent/Caretaker
Which
Child/ren
If more space is needed, attach Extra Page (Form NHJB-2656-FP).
I have attached Form NHJB-2656-FP because additional space was needed.
3. Are there any person(s), not a party to this proceeding, who have physical custody of the child/ren
or who claim to have custody, physical custody or parenting time rights?
Yes No
If yes, list name(s) and address(es) of person(s):
NHJB-2660-DFP (12/01/2010) Page 1 of 2
Instructions
Clear Form
Top of Page
Case Name:
Case Number:
UCCJEA AFFIDAVIT
4. Check one of the following:
I have not participated in any court case(s) concerning the custody, visitation, parenting time
or placement of the child/ren in this or any other state.
OR
I have participated in court case(s) concerning the custody, visitation, parenting time or
placement of the child/ren in this or any other state. I have participated in the following:
Name of Court State Case No. Date of Court Order
5. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic
relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and
responsibilities, termination of parental rights, adoption, juvenile, or other proceedings in any court in
any state affecting any children named in this petition or parents of those children?
Yes No If yes, complete the following:
Name of Court State Case No. Type of Court Case
6. Optional: I am alleging, under oath, that my or my child/ren’s health, safety, or liberty would be
jeopardized by the disclosure of identifying information set forth in this Affidavit. To support my
allegation, I state as follows:
Note: In domestic violence actions under RSA 173-B, the whereabouts of the plaintiff shall not be
released except by court order.
I acknowledge that I have a continuing duty to inform the court of any court action in this or
any other state that could affect the child/ren in this case.
I swear or affirm that the foregoing information is true and correct to the best of my knowledge.
Date Signature of Person Completing Affidavit
Printed Name of Person Completing Affidavit
State of , County of
This instrument was acknowledged before me on
My Commission Expires
Affix Seal, if any
by
Date Person Signing Above
Signature of Notarial Officer / Title
NHJB-2660-DFP (12/01/2010) Page 2 of 2
Top of 1st Page
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THE STATE OF NEW HAMPSHIRE (State of New Hampshire)

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Completed 7 January 2022

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