Connecticut Affidavit Concerning Children Form

Affidavit Concerning Children.pdf File this form with the clerk to identify the minor children of the marriage.Download

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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.	
Judicial District of	At (Town)	
Plaintiff/Applicant  (Last, first, middle initial)
AFFIDAVIT CONCERNING
CHILDREN STATE OF CONNECTICUT
SUPERIOR COURT
COURT OF PROBATE
JD-FM-164 Rev. 6-09
C.G.S. § 46b-115s
P.B. § 25-57 	
Docket number	
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)	
TO      THE PRESENT
TO 	
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 
TO 
TO 	
Child's name  (First, middle, last)	Date of birth (Month, day, year)	
Date(s) of residence	
TO      THE PRESENT
TO 	
Relationship
to child	
TO 
TO 
TO 	
   Residence information is same as for child above.
         (If not same, provide information)                         	
Location
(Town or city, and state, unless confidential by court order)	
  	Check here if additional children are listed on JD-FM-164A.	(Continued...)	
INSTRUCTIONS	
Date(s) of residence	
www.jud.ct.gov	
Name(s) and present address(es) of person(s) child lived with(unless confidential)	
AFFACUS
Court Use Only	
Probate District name and number

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         No             Do not know             If yes, complete the following: 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:
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.
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:
Case name	Docket number	Court location  (Including state)	
Signature
Sworn to before me  (Assistant Clerk/Comm. of Superior Court/Notary Public)
Case name	Docket number	Court location (Including state)	
Child's name	Date of birth (Month, day, year)	
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.	
(Check item 2 or 3 below)
4.(Check one)
2.
3.	
Name:
Address:	
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.	
Nature of proceeding
Nature of proceeding	
 (unless confidential)	
Print name of person signing	
Date signed