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Cour t File N o. STA TE OF NOR TH CAROLI NA Deputy C SC Assi stant C SC Clerk Of Super ior C our t Nam e Of A ffiant ( Type Or Print) R el ati onshi p To A bove N amed C hild Signatur e Of Affiant Date Physi cal Custody Clai med C ustody V isi tati on Rights Notar y SEA L I know o f a person a s listed belo w, who has physica l custody o r claims to have cu stody o r visita tion rights with respect to the abov e named ch ild. Signatur e Of Per son A uthoriz ed T o Admini ster Oaths SWO RN/AFFI RME D AND SUBS CRIBED T O BEFO RE ME N am e A nd A ddress Of Cour t Details Nam e A nd A ddress Of Per son Date Date C ommi ssion E xpires C ounty W here N otar iz ed D ate Of Child C ustody D eterminati on C apaci ty As Partici pant Details I, t he undersigned a ffiant, being first duly swo rn, sa y that during the past fiv e (5 ) years the abov e named minor ch ild has liv ed as fo llo ws: Fr om To Address Name Of Person Lived With Present Address Of Person Present I hav e participated in litigation conce rning the cu stody of the abov e named ch ild. Period Of R esidence I f urther sa y that: (C heck t hose t hat appl y) Count y In T he Gener al C our t O f J u stic e Dis tr ic t C our t Div is io n A FFIDAVI T A S T O ST ATU S O F MI NO R CHILD VER SU S G.S . 50A -209 N am e A nd A ddress Of Defendant Nam e A nd A ddress Of Plai nti ff Date Of B ir th N am e Of M inor Child Bir thpl ace Nam e A nd A ddress Of C ourt © 2011 A dm ini strat iv e Offi ce of the Courts Case N o. AO C-CV- 609, Rev . 7/ 11 I hav e in forma tion about a custody p roceedin g . Examples of custody proceeding include divorce, pro ceeding re lat ed to domestic vio len ce, a protective order, termination of parental rights or adoption that is p\ ending in a court of this or another state and could affect this proceeding.