Free CUSTODY AFFIDAVIT - Connecticut

CUSTODY AFFIDAVIT
JD-JM-30 Rev. 8-00 P.B. 25-57; C.G.S. 52-231a P.A. 99-185 §20

CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov
DOCKET NO. DATE OF BIRTH

ADDRESS OF COURT NAME AND ADDRESS OF CHILD/YOUTH

1. Address(es) where the child has lived for the past five years:

2. Child lived with the following people during the last five years:

3. 4.

There is no proceeding pending in any other court affecting the custody of said child/youth, or The following proceeding(s) affect the custody of said child/youth:
NATURE OF PROCEEDING CASE NAME DOCKET NO. COURT LOCATION (Including state)

Civil Criminal Juvenile Support Probate 5. The following person(s) has/have physical custody or claims to have custody or visitation rights with respect to said child/youth. No one other than the petitioner/respondent Name and address:

6. The custody decree of this Court sought by the subscriber herein would not conflict with or interfere with any other pending proceeding. 7. Any party to this action HAS HAS NOT participated as a party or witness or in any other capacity, in any other proceeding concerning the custody or or visitation with said child/youth. I hereby certify that the foregoing statements are true to the best of my knowledge and belief: Department of Children and Families by duly authorized representative:
SIGNED (Duly authorized representative)

Subscriber, if not agency:
SIGNED (Subscriber)

PRINT OR TYPE NAME OF PERSON SIGNING ABOVE

PRINT OR TYPE NAME OF PERSON SIGNING ABOVE

SUBSCRIBED AND SWORN TO BEFORE ME:

ON (Date)

SIGNED (Notary Public, Asst. Clerk, Comm. Sup. Ct )

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