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D.R.L. § 76-h FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................................. In the Matter of a Proceeding for " Custody " Visitation under the Uniform Child Custody Jurisdiction and Enforcement Act . Petitioner, -against Respondent. ............................................................................................. STATE OF NEW YORK ) :ss.: COUNTY OF ) I [specify name]: being duly sworn, deposes and states the following:

Form UCCJEA-3 (Affidavit--UCCJEA) 8/2002

Docket No. AFFIDAVIT -UCCJEA

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1. I " reside " am located at [specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254]: I am the [specify relationship to child(ren); if foster parent, agency, institution or other relationship, so state]: and am the "Petitioner "Respondent in the above-entitled proceeding. 2. (Upon information and belief) Each child who is the subject of this proceeding resides at: Name Date of Birth Address1

3. (Upon information and belief) During the last five years each child who is the
Specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254.
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subject of this proceeding resided at: Name Address2

Duration (from/to)

4. (Upon information and belief) The name and present address of the person(s) with whom each child resided during the past five years are as follows; Name Address3 Duration (from/to)

5. I [check applicable box(es)]: a. " have " have not participated as a party in other litigation concerning the " custody " visitation of one or more of the same children in " New York State " another state, territory, tribal jurisdiction or country [specify]: [If so, specify court, jurisdiction, children involved, parties, case number, date of determination and status]: b. " have " have not participated as a witness in other litigation concerning the " custody " visitation of one or more of the same children in " New York State " another state, territory, tribal jurisdiction or country [specify]: [If so, specify court, jurisdiction, custody or visitation, children involved, parties, case number, date of determination and status]: c. " have " have not participated as a [specify other capacity]: in other litigation concerning the " custody " visitation of one or more of the same children in " New York State " another state, territory, tribal jurisdiction or country [specify]: [If so, specify court, jurisdiction, custody or visitation, children involved, parties, case number, date of determination and status]: 6. [Check applicable box(es)]: a. " (Upon information and belief) I have the following information regarding a custody proceeding concerning " custody " visitation of one or more of the same child(ren) that is pending in " New York State " another state, territory, tribal jurisdiction

Specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254. Specify address or indicate if ordered to be kept confidential pursuant to Family Court Act §154-b(2) or Domestic Relations Law §254.
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or country [specify specify court, jurisdiction, custody or visitation, children involved, parties, case number, date of determination, and status; if the order has been stayed, so state, including date of stay and expiration, if any]: b. " (Upon information and belief) an order of " custody " visitation of one or more of the same child(ren) has been registered in " New York State " another state, territory, tribal jurisdiction or country [specify court(s) and jurisdiction(s) in which order registered, date of registration(s), court and jurisdiction that issued the order, children covered by the order and date of order, if available]: c. " I have no information regarding any pending custody or visitation proceedings concerning one or more of the same child(ren). 7. a. " The following person(s) not a party to the proceedings (has)(have) physical custody of the child(ren) affected by this proceeding [specify name(s), address(es), which child(ren) and relationship(s) to child(ren)]: b. " I know of no person(s) not a party to this proceeding who (has)(have) physical custody of any of the child(ren) affected by this proceeding. c. " The following person(s) not a party to the proceedings claim(s) to have custody or visitation rights with respect to the child(ren) affected by this proceeding [specify name(s), address(es), which child(ren) and relationship(s) to child(ren)]: d. " I know of no person(s) not a party to the proceedings who claim(s) to have custody or visitation rights with respect to the child(ren) affected by this proceeding. _________________________________
Signature of: " Petitioner " Respondent ____________________________ Print or Type Name _____________________________ Signature of Attorney, if any ______________________________ Attorney's Name (print or type) ______________________________ Attorney's Address and Telephone Number
Sworn to before me this day . . ______________________ (Deputy) Clerk of the Court Notary Public

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