In the _______________ Court for _____________________ County, State of _____________________ Case No.: ____________________ In Re: The Marriage of: ________________________________) and ________________________________)
DECLARATION UNDER THE UNIFORM CHILD CUSTODY JURISDICTION ACT We, the undersigned, ________________________ and ________________, are both parties to this proceeding to determine the custody of a minor child, and under oath state: 1. There is/are __________minor child(ren) subject to this proceeding. For each
child, the name, sex, Social Security number, date and place of birth, and time and place of residence an name and relationship of person child lived with for the past 5 years, is as follows: (Attach additional sheet if necessary). Child’s Name:_______________________________Sex:_____Date of Birth: ______________ Place of Birth: _______________________________Social Security Number:______________ Present Residence: _____________________________________________________________ Person Child Lives With: _________________________ Relationship:____________________ Dates of Residence: From: _____________________To: Present Previous Residence: _____________________________________________________________ Person Child Lived With: ____________________________Relationship:__________________ Dates of Residence: From: _____________________ To: _______________________________ Child’s Name:_______________________________Sex:_____Date of Birth: ______________ Place of Birth: _______________________________Social Security Number:______________ Present Residence: _____________________________________________________________
Person Child Lives With: _________________________ Relationship:____________________ Dates of Residence: From: _____________________To: Present Previous Residence: _____________________________________________________________ Person Child Lived With: ____________________________Relationship:__________________ Dates of Residence: From: _____________________ To: _______________________________ 2. Neither party has participated as a party, witness or any other capacity in any
other court decision, order, or custody proceeding in this state or any other state, concerning the custody of a child subject to this proceeding. 3. Neither party has any information concerning any other court decision ,order, or
custody proceeding in this state or any other state concerning the custody of a child subject to this proceeding. 4. Neither party knows of any other person who is not already a party to this
proceeding who has physical custody of, or who claims to have custody or visitation rights with, any child subject to this proceeding. Signed in the presence of: ________________________________ Signature ________________________________ Print or Type Name _______________________________ Signature _______________________________ Print or Type Name ____________________________________ Wife’s Signature Date: __________________________
_______________________________ Signature ________________________________ Print or Type Name _____________________________ Signature _______________________________ Print or Type Name
____________________________________ Husband’s Signature Date: ___________________________
STATE OF _____________________) COUNTY OF ___________________) The foregoing instrument was acknowledged before me this ___ day of________, 200__, by_____________________________ [ ] who is personally known to me [ ] or has produced __________________ as identification.
(Notary Seal)
___________________________________ Signature of Notary Public Print Name:___________________ Title: Notary Public Serial No. (if any)___________
STATE OF _____________________) COUNTY OF ___________________) The foregoing instrument was acknowledged before me this ___ day of________, 200__, by_____________________________ [ ] who is personally known to me [ ] or has produced __________________ as identification.
(Notary Seal)
___________________________________ Signature of Notary Public Print Name:___________________ Title: Notary Public Serial No. (if any)___________
IF A NONLAWYER ASSISTED YOU FILL OUT THIS FORM, THEY MUST FILL IN ALL THE BLANKS BELOW: I (name of person) _____________________________, am a nonlawyer residing at (street) _______________________, (city) _____________________, (state) _____, (phone) _______ helped (name of spouse) ____________________, who is the _____ petitioner or _____ respondent, fill out this document.