Fill and Sign the Uccjea Template Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF ________________ In the Matter of the Marriage of: ) ) Case No. ____________________ ________________________________, ) Petitioner, ) RESPONSE WITH UCCJEA INFORMATION ) and ) DOMESTIC RELATIONS CASE SUBJECT TO FEE UNDER ORS ) 21.111 ________________________________, ) Respondent. ) Response Respondent appears and agrees with the petition for dissolution filed in this case, except as specifically stated below: (I ) _______________________________________________________________ ________________________________________________________________________ Response with UCCJEA Information 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ________________________________________________________________________ (II) _______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (III) _______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (IV) _______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Information Required by the Uniform Child Custody Jurisdiction and Enforcement Act. (Please fill in the following blanks) a. The parties’ minor child/ren are: _______________________________________ Response with UCCJEA Information 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ________________________________________________________________________ ________________________________________________________________________ b. The child/rens’ present residence, mailing, or contact address is: _____________ ________________________________________________________________________ ________________________________________________________________________ c. The places where the minor child/ren of the parties have lived in the last five years and the names of the person with whom the child/ren have resided are: Dates County/State With Whom Which Children From:______ to _______ _____________ _______________ ________________ From: _____ to _______ _____________ _______________ ________________ From: _____ to _______ _____________ _______________ ________________ From: _____ to _______ _____________ _______________ ________________ _ Additional page attached; see section labeled “paragraph C continued.” Response with UCCJEA Information 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 d. The current addresses of the persons listed above with whom the minor child/ren have lived are: Name Address ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ e. _ I have not participated in any litigation concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state, (or) _ I have participated in the following litigation concerning the custody, visitation, parenting time or placement: Name of Court State Case No . Date Result ________________________________________________________________________ ________________________________________________________________________ f. Except as stated below, I do not have any knowledge of any other domestic violence, custody, visitation, parenting time or placement proceeding involving the child/ren of this marriage pending in this or another state: ________________________________________________________________________ (Identify court, case number and the nature of the proceeding) ________________________________________________________________________ Response with UCCJEA Information 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 g. Except as stated below, I do not know any person other than my spouse who has physical custody of the child/ren or who claims to have custody, visitation or parenting time rights: ________________________________________________________________________ (list name and address) ________________________________________________________________________ Certificate of Document Preparation I certify that: (check all that apply) _ I selected this document for myself. _ I was provided this document by an attorney. _ I completed this document without paid assistance. _ I paid or will pay money to _______________________ for assistance in preparing this document/form. STATE OF OREGON ) ) Response with UCCJEA Information 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 County of Marion ) I, _______________________________, being duly sworn, say that I am the (print name) respondent in this matter, and that the statements in this Response are true and correct to the best of my knowledge. _________________________________________ Signature _________________________________________ Print Name _________________________________________ Address _________________________________________ City, State, Zip Code _________________________________________ Telephone SUBSCRIBED AND SWORN TO before me this ______ day of ____________________, ______, by _________________________________________. __________________________________________ Notary Public for ____________/Court Clerk My Commission Expires: _______________ I certify that this is a true copy. _____________________________________ Respondent, Pro Se (Signature) Response with UCCJEA Information 6