Free AFFIDAVIT CONCERNING CHILDREN - Connecticut

AFFIDAVIT CONCERNING CHILDREN
JD-FM-164 Rev. 6-09 C.G.S. § 46b-115s P.B. § 25-57

INSTRUCTIONS Complete form. You must swear that your statement is true and sign it in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit.
At (Town) Probate District name and number

STATE OF CONNECTICUT SUPERIOR COURT COURT OF PROBATE
www.jud.ct.gov
Court Use Only

AFFACUS
Docket number

Judicial District of Plaintiff/Applicant (Last, first, middle initial)

Defendant/Respondent (Last, first, middle initial)

Information about the past five years for each child affected by this case is required. Provide information below. If more space is needed, use form JD-FM-164A.
Child's name (First, middle, last) Date of birth (Month, day, year)

Date(s) of residence

Location (Town or city, and state, unless confidential by court order)

Name(s) and present address(es) of person(s) child lived with (unless confidential)

Relationship to child

TO

THE PRESENT

TO

TO

TO

TO

Child's name (First, middle, last)

Date of birth (Month, day, year)

Residence information is same as for child above. (If not same, provide information) Relationship to child

Date(s) of residence

Location (Town or city, and state, unless confidential by court order)

Name(s) and present address(es) of person(s) child lived with (unless confidential)

TO

THE PRESENT

TO

TO

TO

TO

Check here if additional children are listed on JD-FM-164A.

(Continued...)

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1. (Check one) I have I have not been a party or a witness or participated in any other capacity in cases in Connecticut or any other state concerning custody of or visitation with any child listed in this affidavit. If yes, identify the name of the court, the court case number and date of determination:

(Check item 2 or 3 below) 2. I do not know of other civil or criminal proceedings in Connecticut or any other state, now or in the past, that could affect the current proceeding, including enforcement proceedings and proceedings relating to family violence, protective orders, termination of parental rights and adoption. I know of the following civil or criminal proceedings, in Connecticut or any other state, now or in the past, that could affect the current proceeding, including enforcement proceedings and proceedings relating to family violence, protective orders, termination of parental rights and adoption.
Docket number Court location (Including state)

3.

Case name Nature of proceeding Case name Nature of proceeding

Docket number

Court location (Including state)

4. (Check one)

No one except the plaintiff/applicant and defendant/respondent has physical custody or claims to have custody or visitation rights regarding any child listed here. The following person(s) has physical custody or claims to have custody or visitation rights regarding any child listed here: Name: Address: (unless confidential)

5. The mother of the child(ren) named in the Complaint or Application is pregnant. Yes No Do not know

6. A child has been born to the mother named in the Complaint or Application after the filing of the Complaint or Application. Yes
Child's name

No

Do not know

If yes, complete the following:
Date of birth (Month, day, year)

Signature Sworn to before me (Assistant Clerk/Comm. of Superior Court/Notary Public)

Print name of person signing Date signed

JD-FM-164 (Back) Rev. 6-09

You have an ongoing duty to tell the court about any case that could affect the current proceeding, in Connecticut or any other state, if you learn about it during this case.

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