Uniform Child Custody Jurisdiction and Enforcement Act
AFFIDAVIT of CHILD CUSTODY
I, _______________________________________, hereby state that the following facts are true to the best of my
(Print Name)
knowledge and belief:
1. I am the
☐ Plaintiff in this case.
☐ Defendant in this case.
2. I am the
☐ Biological or adoptive mother;
☐ Biological or adoptive father;
☐ Other: ________________________________________
for the child(ren) who is/are the subject(s) of this proceeding.
3. During the last five years, the children have lived at the following addresses with the following household
members:
(Begin with the child’s residence just before this court case started and list all addresses for the past five (5) years.)
Address Dates From Name of All Persons Residing
(Street, City, State) When to When in the Household with the Child
_________________________________ ___________to___________ ____________________________
_________________________________ ___________to___________ ____________________________
_________________________________ ___________to___________ ____________________________
Use an additional page if you need more space. If children have lived at different addresses from each other please
indicate the addresses for each child.
(A) 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:
(B) Please answer the following questions by checking the box if the statement is true. If your answer to any of
the questions is “yes”, please explain your answer on an additional page.
(i) I have participated as a party, witness, or in some other way in a court case about the custody of this
child/these children in Vermont or another state.
☐ Yes ☐ No
(ii) I have information about a custody case concerning this child/these children that is now pending in a Vermont
court or a court in another state.
☐ Yes ☐ No
(iii) I have knowledge about a person who is not a party to this case who has physical custody of this child/these
children or who claims to have custody or visitation rights to this child/these children.
☐ Yes ☐ No
I hereby swear under penalty of perjury that the information above is true and correct to the best of my knowledge and
belief.
Dated
___________________ ____________________________________
Signature
____________________________________
Print Name
Signed and sworn to before me:
Date: ___________________________
Expiration Date: ___________________ Signature of Notary: ____________________________________
