Free IN THE SUPERIOR COURT FOR THE STATE OF ALASKA - Alaska

If you believe that disclosure of some of the information on this form would jeopardize your health, safety or liberty or that of your children, you are not required to serve a copy of this form on the other party. Instead, file this form with the court along with court form DR-151 (available at the clerk's office). AS 25.30.380(e) IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) ) ) I, 1.

CASE NO. CHILD CUSTODY JURISDICTION AFFIDAVIT

, say on oath or affirm under penalty of perjury that: The following children are the subject of the present custody proceedings:
Place of Birth ): City & State Who Has Custody Person Child Lived With (Name & Current Address) Birthdate Sex Relationship Relationship

Child's Name Present Address (since Prior Residences for past 5 years (dates) to to to to

Child's Name Present Address (since Prior Residences for past 5 years (dates) to to to to / / ): City & State

Place of Birth Who Has Custody

Birthdate

Sex Relationship Relationship

Person Child Lived With (Name & Current Address)

Page 1 of 3 DR-150 (3/03) (cs) CHILD CUSTODY AFFIDAVIT

AS 25.30.380

Child's Name Present Address (since Prior Residences for past 5 years (dates) to to to to / / ): City & State

Place of Birth Who Has Custody

Birthdate

Sex Relationship Relationship

Person Child Lived With (Name & Current Address)

Child's Name Present Address (since Prior Residences for past 5 years (dates) to to to to / / ) City & State

Place of Birth Who Has Custody

Birthdate

Sex Relationship Relationship

Person Child Lived With (Name & Current Address)

Child's Name Present Address (since Prior Residences for past 5 years (dates) to to to to / / ) City & State

Place of Birth Who Has Custody

Birthdate

Sex Relationship Relationship

Person Child Lived With (Name & Current Address)

Page 2 of 3 DR-150 (3/03) (cs) CHILD CUSTODY AFFIDAVIT

AS 25.30.380

2. Have you participated as a party, a witness or in another capacity in another proceeding concerning the custody of any of the above children or visitation with them? Yes No If yes, describe the previous child custody determination: Name of Court Case Number Court's Decision:

Date

3. Do you know of a proceeding that could affect the current proceeding (including a proceeding relating to domestic violence, protective orders, termination of parental rights, adoption or enforcement of a court order)? Yes No If so, describe: Name of Court Nature of Proceeding: Case Number

4. Do you know of any person not a party to this proceeding who has physical custody of any of the above children or claims to have the right to physical custody, legal custody, or visitation? Yes No If so, list each person's name and address and what the person claims:

I swear or affirm under penalty of perjury that my statements in this affidavit are true to the best of my knowledge and belief.

Signature Subscribed and sworn to or affirmed before me at . on Date (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My Commission Expires: I certify that on a copy of this affidavit was mailed to the other party in this case (list name): , Alaska,

Signature: Note: Each party has a continuing duty to inform the court of any other court proceeding in this state or any other state concerning any of the children listed above.
Page 3 of 3 DR-150 (3/03) (cs) CHILD CUSTODY AFFIDAVIT AS 25.30.380