Fill and Sign the Form 834 Uccja Affidavit

400 -00834 - UCCJEA Affidavit of Child Custody (01/2018) Page 1 of 1 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Uni form Child Custody Jurisd iction a n d E n f o r c e m e n t Act AFFI D AVIT of CH ILD 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. ☐ Defend ant in this cas e. 2. I am the ☐ Biological or ado ptive mother; ☐ Biological or ado ptive father; ☐ Other: ________________________________________ for the child(ren) who is/are the subject (s) of this proce eding. 3. During the last five years, the children hav e lived at the followi ng address es with the following household member s: (Begin with the child’s residence just before this cou rt 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 additiona l pa ge if you need more space. If children have lived at differe nt addresses from each other please indicate the add resses for each child. (A) If the curre nt add ress of any hous ehold membe r listed in the last column is different from the address listed above, please prov ide a current address for that pers on: (B) Please ans wer the followi ng questions by chec king the box if the statement is true. If your ans wer to any of the ques tions is “y es”, please explain your answer on an additional page. (i) I have participated as a party, witness, or in som e other way in a court case about the custody of this child/these children in Vermo nt or another state. ☐ Yes ☐ No (ii) I have inform ation abo ut a custody case concerning this child/these children that is now pending in a Vermon t court or a cou rt in ano ther state. ☐ Yes ☐ No (iii) I have kn owledge abou t a person who is not a party to this case who has ph ysical custod y 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: ____________________________________