UCCJEA Child Custody Affidavit

UCCJEA CHILD CUSTODY AFFIDAVIT

State:    County:

I, Affiant Name: , being duly sworn, state under oath the following facts based on my personal knowledge and information and belief.

RECITALS

WHEREAS, Affiant is a person with direct knowledge of the facts concerning the physical custody and habitual residence of the minor child(ren) identified herein; and

WHEREAS, a custody proceeding may be pending or has previously been decided in another state or jurisdiction and factual information regarding prior orders, physical custody, and removal or retention of the child(ren) is material to jurisdictional determinations under the Uniform Child Custody Jurisdiction and Enforcement Act ("UCCJEA"); and

WHEREAS, Affiant makes this affidavit to provide the court with a sworn statement of the child(ren)'s residence history, prior custody proceedings, and other facts relevant to jurisdiction and enforcement.

NOW THEREFORE, Affiant states as follows:

1. CHILD(REN) IDENTIFICATION

Child Full Legal Name:

Date of Birth:    Sex:

2. PARTIES AND RESIDENCE HISTORY

Affiant Relationship to Child:

Other parent/party Name:

Period child has resided in this state: (describe continuous residence and any interruptions in Section 4 below)

3. PRIOR PROCEEDINGS AND ORDERS

Has there been any prior custody, guardianship, protection or related proceeding concerning the child(ren) in any state or jurisdiction?    Yes    No

Have any orders been registered for enforcement in this state?    Yes    No

4. BASIS FOR JURISDICTION UNDER UCCJEA

Affiant asserts jurisdiction in this state is proper under the following UCCJEA ground(s) (check all that apply) and state the specific supporting facts in the space provided:

Home state jurisdiction — this state was the child's home state within six months before the commencement of this proceeding and the child is currently present in this state.

Significant-connection jurisdiction — the child and at least one parent have a significant connection with this state other than physical presence, and substantial evidence concerning the child's care, protection, training, and personal relationships is available in this state.

5. REMOVAL, ABDUCTION, OR EMERGENCY CIRCUMSTANCES

Has the child been removed from or wrongfully retained outside the child's habitual residence within the last 60 days?    Yes    No

6. LAW ENFORCEMENT / CHILD WELFARE CONTACTS

7. REPRESENTATIONS, CERTIFICATION AND AUTHORIZATION

Affiant certifies that the information contained in this affidavit is true and correct to the best of Affiant's knowledge and belief. Affiant acknowledges that knowingly providing false information in this affidavit may subject Affiant to penalties including contempt of court and criminal sanctions under applicable law.

Affiant authorizes the release of relevant records and information to the court and to the parties in interest for purposes of determining jurisdiction and enforcing any custody or visitation order.

8. NOTICES, AMENDMENTS, AND WAIVER

Any notice required or permitted under this affidavit shall be effective upon personal service or upon deposit in the United States mail, postage prepaid, addressed to the last known address provided herein. This affidavit may be amended by a supplemental sworn affidavit filed with the court. No waiver of any provision shall be valid unless in writing and signed by the waiving party.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This affidavit shall be governed by and construed in accordance with the laws of the State specified above and the provisions of the Uniform Child Custody Jurisdiction and Enforcement Act as adopted in that State. This affidavit constitutes the entire sworn statement of Affiant with respect to the matters set forth herein. If any provision of this affidavit is held unenforceable, the remaining provisions shall remain in full force and effect.

VERIFICATION

I declare under penalty of perjury under the laws of the State specified above that the foregoing is true and correct.

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