Affidavit for UCCJEA Information

________________________ appeared in person before me today and stated under oath:

"My name is __________________________________. I am competent to make this affidavit. The facts stated in this affidavit are within my personal knowledge and are true and correct.

"I am the Petitioner in this case.

"The child(ren)'s present address is __________________________________________.

"For the past five years immediately preceding the date of this affidavit, the child has lived at the following addresses with the following people:

Address: _____________________________________________________________________

People lived with: ______________________________________________________________

From __________________ until ____________________.

Address: _____________________________________________________________________

People lived with: ______________________________________________________________

From __________________ until ____________________.

Address: _____________________________________________________________________

People lived with: ______________________________________________________________

From __________________ until ____________________.

Address: _____________________________________________________________________

People lived with: ______________________________________________________________

From __________________ until ____________________.

Address: _____________________________________________________________________

People lived with: ______________________________________________________________

From __________________ until ____________________.

"The present addresses of the people listed above are:

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

A. _______ "I have not participated, as a party or as a witness or in any other capacity, in any other proceeding concerning the custody of or visitation with the child in Texas or any other state.

B. _______ "I have participated as a ________________________________________ in other proceedings concerning the custody of or visitation with the child in ____________ in cause number _________________________ in ____________________________________.

(1) _______ A child custody determination was made in that proceeding on the _______ day of __________________________, _________.

(2) _______ A child custody determination was made in that proceeding on the _______ day of __________________________, _________.

C. _______ "I do not know of any proceeding that could affect this proceeding, including proceedings for enforcement and proceedings relating to domestic violence, protective orders, termination of parental rights, and adoptions.

D. _______ "The following proceeding could affect the current proceeding: Court: ____________________________, Cause Number _______________________________, _________________________________________________________________________.

E. _______ "I do not know of any person not a party to this proceeding who has physical custody of the child or claims rights of legal custody or physical custody of, or visitation with, the child.

F. _______ "The following persons have physical custody of the child:

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________"

G. _______ "The following persons claim rights of legal custody with the child:

Name: _____________________________________

Address: __________________________________________________________ Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

H. _______ "The following persons claim rights of physical custody with the child:

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

I. _______ "The following persons claim rights of visitation with the child:

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

Name: _____________________________________

Address: __________________________________________________________

____________________________________ Signature

SIGNED under oath before me on ________________________________.

____________________________________

Notary Public, State of Texas