Fill and Sign the Affidavit Uniform Child Custody Jurisdiction and Enforcement Act

AFFIDAVIT (Uniform Child Custody Jurisdiction and Enforcement Act) Case No. ....................................................................................... COMMONWEALTH OF VIRGINIA Va. Code § 20-146.20 [ ] Circuit Court ....................................................................................................................................................................... [ ] Juvenile and Domestic Relations District Court In re: .................................................................................................................................................................................................................................................................... JUVENILE .............................................................................................................................. v. ............................................................................................................................... I, ................................................................................................................................... the undersigned affiant, state the following information under oath: [ ] Certain information has been omitted from this form and submitted under seal because I allege that the health, safety or liberty of a party or child would be jeopardized by disclosure. Another part y may request that a hearing be held to determine whether this information should be disclosed. 1. The child presently resides at: .......................................................................................................................................................................................................... ADDRESS The c DATE hild commenced residing there on ...................................................................................... and has resided there continuously to this date. 2. The other places where and persons with whom this child has liv ed during the last five (5) years : (please complete reverse side). 3. I [ ] have [ ] have not participated, either as a part y, witness, or in any other capacity in any other litigation (court proceeding) concerning custody of or visitation with this child, in an y State or foreign country. If yes, complete below: a. Name of Court and State or foreign country in which litigation occurred: ............................................................................................................ b. When did the litigation occur: .................................................................................................................................................................................................. c. What was the outcome of the litigation: ............................................................................................................................................................................... d. Attach a copy of all pleadings and Orders filed in this litigation. 4. I [ ] do [ ] do not have knowledge or information of any proceeding that could affect this proceeding, including but not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domest ic violence, protective orders, abuse and neglect, termination of parental rights and adoptions, which is pending in a court of th is or any other State or foreign country. If yes, complete below: a. Name of Court and State or foreign country in which proceeding is pending: ..................................................................................................... ................................................................................................................................................................................................................................................................ b. Attach a copy of all pleadings filed in the litigation. 5. I [ ] do [ ] do not know of any person who is not already named as a party in this proceeding who has physical custody of this child or who claims to have custody or visitation rights with respect to child. If yes: a. Name and address of person: .................................................................................................................................................................................................... b. Does this person have physical custody of the child? [ ] Yes [ ] No c. State why you believe this person claims to have custody/visitation rights to the child: ................................................................................. ..................................................................................................................................................................................................................................................................... 6. I understand that I have an obligation to promptly inform th is court if I later become aware of any other proceedings, inclu ding but not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective orders, abuse and neglect, termination of parental rights and adoptions, either in this or an y other State or foreign country that could affect the current proceeding. ________________________________________________ SIGNATURE OF AFFIANT Subscribed and sworn to before me on ................................................. DATE Title: ............................................................................................................ ____________________________________________________________ SIGNATURE FOR NOTARY PUBLIC’S USE ONLY: State of ................................................................................................ [ ] City [ ] County of ................................................................................................ Acknowledged, subscribed and sworn to before me this ...................... day of .................................................................................... , 20 ............... ......................................................................................... ________________________________________________________ NOTARY REGISTRATION NUMBER NOTARY PUBLIC (My commission expires: ................................) FORM DC-620 (FRONT) 05/08 AFFIDAVIT (continued) Question #2: Places where a nd persons with whom the child has lived during the last five (5) years. PERSON CURRENT ADDRESS OF PERSON DATE ADDRESS WHERE CHILD RESIDED WITH WHOM CHILD RESIDED WITH WHOM CHILD RESIDED From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ 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From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ From ........................................................ ...................................................................... .......................... ................................................................................... ................ ....................................................................... To ............................................................. ................................................................. ............................... ................................................................................... ........... ............................................................................ FORM DC-620 (REVERSE) 11/96