Free Temporary Child Information Affidavit, DC 6:5(8) - Nebraska

Neb.Rev.Stat. §43-2930 (2008)(1) states that a Temporary Child Information Affidavit shall be offered as an exhibit by each party to a contested proceeding for a temporary order relating to custody, etc. The affidavit may include items specified by statute, including those listed below; and others as necessary.

STATE OF NEBRASKA FORM NO. DC 6:5(8) Rev. 7/08 Neb. Rev. Stat. 43-2930

TEMPORARY CHILD INFORMATION AFFIDAVIT

CASE NUMBER:

IN THE DISTRICT COURT OF __________________________ COUNTY, NEBRASKA ____________________________, Plaintiff, vs. ___________________________, Defendant.

TEMPORARY CHILD INFORMATION AFFIDAVIT

STATE OF NEBRASKA

) ) COUNTY OF _____________________ )
(county where signed)

ss.

I, ______________________________, being first duly sworn, state as follows:
(your full name)

1.

I am the __________________________ in this action.
(plaintiff or defendant)

2.

My spouse/the other parent and I have _______ child(ren). Their names
(circle one)

and years of birth are: _____________________________________ _________________
(full name of child) (full name of child) (full name of child) (full name of child) (child's year of birth) (child's year of birth) (child's year of birth) (child's year of birth)

_____________________________________ _________________ _____________________________________ _________________ _____________________________________ _________________

3.

Following are the names and addresses of all adults with whom the above

child(ren) has/have lived with for the past twelve (12) months: DATES OF RESIDENCE
(from mo./yr. to mo./yr.)

NAME OF ADULT
(name of adult)

ADDRESS
(adult's address)

NAME OF CHILD
(name of child living with adult)

_________________ ___________________ __________________ _____________ _________________ ___________________ __________________ ____________
(name of adult) (adult's address) (name of child living with adult) (from mo./yr to mo./yr.)

_________________ ___________________ __________________ ____________
(name of adult) (adult's address) (name of child living with adult) (from mo./yr. to mo.yr.)

_________________ ___________________ __________________ ____________
(name of adult) (adult's address) (name of child living with adult) (from mo./yr. to mo./yr.)

4.

During the past 12 months, I have provided for the daily needs of the

child(ren) in the following ways: ______________________________________________________________________
(list of daily needs you have provided for the child(ren) in the last 12 months)

______________________________________________________________________ ______________________________________________________________________

5.

During the past 12 months, my spouse/the other parent has provided for
(circle one)

the daily needs of the child(ren) in the following ways: ______________________________________________________________________
(list of daily needs your spouse/the other parent has provided for the child(ren) in the last 12 months)

______________________________________________________________________ ______________________________________________________________________

6.

During the past 12 months, my work schedule has been as follows:
(describe your work schedule over the past 12 months)

______________________________________________________________________

______________________________________________________________________ ______________________________________________________________________ 7. During the past 12 months, my child(ren)'s child care schedule has been

as follows: ______________________________________________________________________
(describe your child(ren)'s child care schedule over the past 12 months)

______________________________________________________________________ ______________________________________________________________________ 8. Check the box that applies: [ ] At this time, I do not expect a change to my work schedule. OR [ ] At this time, I expect the following change(s) to my work schedule:
(list expected change(s) to your work schedule)

__________________________________________________________ __________________________________________________________ __________________________________________________________

9.

Check the box that applies: [ ] At this time, I do not expect a change to my child(ren)'s child care schedule. OR [ ] At this time, I expect the following change(s) to my child(ren)'s child care schedule:

________________________________________________________
(list expected change(s) to your child(ren)'s child care schedule)

________________________________________________________ ________________________________________________________

10.

Check the box that applies: [ ] The child(ren) is/are not involved in any school-related or extracurricular activites. OR [ ] The child(ren) is/are involved in the following school-related or extracurricular activities: PARTY RESPONSIBLE FOR TRANSPORTATION _____________________
(party responsible for transportation) (activity)

ACTIVITY ___________________________________

____________________________________ _____________________
(activity) (party responsible for transportation)

____________________________________ _____________________
(activity) (party responsible for transportation)

____________________________________ _____________________
(activity) (party responsible for transportation)

11.

Check the box that applies: [ ] There are no circumstances of child abuse or neglect, domestic abuse, or unresolved conflict with my spouse/the other parent that
(circle one)

would justify any limitation on custody, parenting time, visitation, or other access to the child(ren).

OR [ ] There are circumstances of child abuse or neglect, domestic abuse, or unresolved conflict with my spouse/the other parent that would
(circle one)

justify a limitation on custody, parenting time, visitation, or other access to the child(ren). Following are the details (including details of any previously filed restraining orders, protection orders, or criminal no-contact orders): _____________________________________________________
(list circumstances justifying limitation)

_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

Dated this ________ day of _________________, _____.

________________________________
(print your name)

________________________________
Signature

________________________________
Street address

________________________________
City, State, ZIP code

________________________________
Telephone number

SUBSCRIBED AND SWORN to before me this _____ day of _______________, _______. ________________________________
Notary Public

CERTIFICATE OF SERVICE I hereby certify that on the _______ day of _______________, ______, a true copy of the foregoing Temporary Child Information Affidavit was sent by first-class mail, postage prepaid, to my spouse at _________________________________________
(spouse's address, including street address, city, state, and ZIP code) _________________________________________________.

________________________________
(your name)