AFFIDAVIT CONCERNING CHILDREN
JD-FM-164 Rev. 1-22
C.G.S. § 46b-115s; P.A. 21-15; P.B. § 25-57
STATE OF CONNECTICUT
SUPERIOR COURT
COURT OF PROBATE
www.jud.ct.gov
You must provide information about the past five years for each child affected by this case. Provide the information below.
If you need more space, use form JD-FM-164A.
To The present
To
Place of residence
(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
Page 1 of 2
Instructions:
Fill out this form completely.
You must swear that your statements are true and sign this form in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit.
Date(s) of residence
AFFACUS
Court Use Only
Judicial District of
At (Town)
Probate District name and number Docket number
Plaintiff/Applicant's name (Last, first, middle initial) Defendant/Respondent's name (Last, first, middle initial)
Child's name (First, middle, last) Date of birth (Month, day, year)
(date)
(date)
(date)
(date)
(date)
Child's name (First, middle, last) Date of birth (Month, day, year)
Residence information is same as for child above.
(If not same, provide information)
Select here if additional children are listed on JD-FM-164A.
To
To
To
To
(date)
(date) (date)
(date) (date)
(date) (date)
(date) (date)
From
From
From
From
From
From
From
From
From
From
(date)
(date)
(date)
(date)
*AFFACUS*
Relationship
to child
Name(s) and present address(es) of person(s)
child lived with
(unless confidential)
Place of residence
(Town or city, and state, unless
confidential by court order)
Date(s) of residence
To The present
This form is available
in other language(s).
Print Form
Reset Form
5. The parent of the child(ren) named in the Complaint or Application is pregnant.
6. A child has been born to the parent named in the Complaint or Application after the filing of the Complaint or Application.
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 cases in Connecticut or another state, now or in the past, that could affect the
current case, including enforcement cases and family violence, protective order, termination of parental rights and
adoption cases.
1. (Select one)
been involved as a party or a witness or in any other capacity in a case
or cases in Connecticut or in another state concerning custody of or visitation with any child listed in this affidavit. If you
selected "I have," give the name of the court, the court case number and the date of the decision in the case or cases:
Signature
Sworn to before me (Assistant Clerk/Commissioner of Superior Court/Notary Public)
JD-FM-164 Rev. 1-22
You must tell the court about any case in
Connecticut or another state that could affect
this case, if you learn about it during this case.
(Select item 2 or 3 below)
4. (Select one)
I know of the following civil or criminal cases, in Connecticut or another state, now or in the past, that could affect the
current case, including enforcement cases and family violence, protective order, termination of parental rights and
adoption cases.
(unless confidential)
I have I have not
2.
3.
Case name
Docket number
Court location (Including state)
Nature of proceeding
Case name Docket number
Court location (Including state)
Nature of proceeding
Name:
Address:
Yes
No Do not know
Yes
No Do not know If yes, fill in the following:
Child's name
Date of birth (Month, day, year)
Print name of person signing
Date signed
Page 2 of 2
ADA NOTICE
The Judicial Branch of the State of
Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a
reasonable accommodation in accordance
with the ADA, contact a court clerk or an ADA
contact person listed at www.jud.ct.gov/ADA.
Print Form
Reset Form
