Fillable Printable Uniform Child Custody Jurisdiction and Enforcement Act Affidavit
Fillable Printable Uniform Child Custody Jurisdiction and Enforcement Act Affidavit
Uniform Child Custody Jurisdiction and Enforcement Act Affidavit
AFFIDAVIT (Uniform Child Custody Jurisdiction and Enforcement Act) Case No. .......................................................................................
COMMONWEALTH OF VIRGINIA Va. Code § 20-146.20
[ ] Circuit Court
.......................................................................................................................................................................
[ ] Juvenile and Domestic Relations District Court
In re:
....................................................................................................................................................................................................................................................................
JUVENILE
.............................................................................................................................. v. ...............................................................................................................................
I, ................................................................................................................................... the undersigned affiant, state the following information under oath:
[ ] Certain information has been omitted from this form and submitted under seal because I allege that the health, safety or liberty of a
party or child would be jeopardized by disclosure. Another party may request that a hearing be held to determine whether this
inform at i on should be disclosed.
1. The child presen tly resides at: ..........................................................................................................................................................................................................
ADDRESS
The c
DATE
hild commenced residing there on ...................................................................................... and has resided there continuously to this date.
2. The other places where and persons with whom this child has lived during the last five (5) years : (please complete reverse side).
3. I [ ] have [ ] have not participated, either as a party, witness, or in any other capacity in any other litigation (court proceeding)
concerning custody of or visitation with this child, in any State or foreign countr y. If yes, complete below:
a. Name of Court and State or foreign coun try in which litigation occurred: ............................................................................................................
b. When did the litigation occur:
..................................................................................................................................................................................................
c. What was the outcome of the litigation:
...............................................................................................................................................................................
d. Attach a copy of all pleadings and Orders filed in this litigation.
4. I [ ] do [ ] do not have knowledge or information of any proceeding that could affect this proceeding, including but not limited to
custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective orders, abuse
and neglect, termination of parental rights and adoptions, which is pending in a court of this or any other State or foreign country.
If yes, complete below:
a. Name of Court and State or foreign country in which proceeding is pending:
.....................................................................................................
................................................................................................................................................................................................................................................................
b. Attach a copy of all pleadings filed in the litigation .
5. I [ ] do [ ] do not know of any person who is not already named as a party in this proceeding who has physical custody of this
child or who claims to have custody or visitation rights with respect to child. If yes:
a. Name and address of person: ....................................................................................................................................................................................................
b. Does this person have physical custody of the child?
[ ] Yes [ ] No
c. State why you believe this person claims to have custody/visitation rights to the child: .................................................................................
.....................................................................................................................................................................................................................................................................
6. I understand that I have an obligation to promptly inform this court if I later become aware of any other proceedings, including but
not limited to custody, visitation, paternity, support, enforcement proceedings, proceedings related to domestic violence, protective
orders, abuse and neglect, termination of parental rights and adoptions, either in this or any other State or foreign country that could
affect the current proceeding.
________________________________________________
SIGNATURE OF AFFIANT
Subscribed and sworn to before me on .................................................
DATE
Title: ............................................................................................................ ____________________________________________________________
SIGNATURE
FOR NOTARY PUBLIC’S US E ONLY:
State of ................................................................................................ [ ] City [ ] County of ................................................................................................
Acknowledged, subscribed and sworn to before me this ...................... day of ...................................................................................., 20 ...............
......................................................................................... ________________________________________________________
NOTARY REGISTRATION NUMBER NOTARY PUBLIC
(My commission expires:
................................)
FORM DC-620 (FRONT) 05/08
AFFIDAVIT (continued) Question #2: Places where and persons with whom the child has lived during the last five (5) years.
PERSON CURRENT ADDRESS OF PERSON
DATE ADDRESS WHERE CHILD RESIDE D WITH WHOM CHILD RESIDED WITH WHOM CHILD RESIDED
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
From ........................................................ ................................................................................................ ................................................................................... .......................................................................................
To ............................................................. ................................................................................................ ................................................................................... .......................................................................................
FORM DC-620 (REVERSE) 11/96
