COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO
:
Petitioner	Case No.
:
:	Judge:
v.
:
INFORMATION FOR PARENTING PROCEEDING AFFIDAVIT (R.C. 3127.23)
Respondent	:
(Filed with Form 10.01-D: Petition for Domestic Violence Civil Protection Order)
Use this form if you are requesting a parenting (custody or visitation) order in your Domestic Violence Civil Protection Order Petition (Form 10.01-D). If another court is already addressing or has addressed custody issues involving the children, custody and visitation issues may be handled in that case. By law, this form must be filed and served with the first pleading filed by each party in every parenting (custody or visitation) proceeding in this Court including a Petition for a Domestic Violence Civil Protection Order. If you need more space, attach an additional page.
I (full legal name)	, state under oath or affirmation that these
cases involve the custody of a child or children and the following statements are true:
1.	Pursuant to R.C. 3127.23(D), I am requesting that the Court not disclose my current address or that of the children. My address is confidential and should be placed under seal because my health, safety, or liberty or that of the children would be jeopardized by the disclosure of the identifying information.
2.	(number) Minor children are subject to this case as follows:
(NOTE: Provide residence information for the last FIVE years.)
a. Child’s Name:	Date of Birth:
Period of Residence	Address (Do not list your address if confidential)	Person with whom Child Lived and Relationship to Child
to present	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
b. Child’s Name:	Date of Birth:
Check this box if the information requested below is the same as above.
Period of Residence	Address (Do not list your address if confidential)	Person with whom Child Lived and Relationship to Child
to present	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
c. Child’s Name:	Date of Birth:
Check this box if the information requested below is the same as above.
Period of Residence	Address (Do not list your address if confidential)	Person with whom Child Lived and Relationship to Child
to present	Address Confidential
to	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
to	Address Confidential Secretary of State Address Confidentiality Program
d.	List additional children on a page titled Attachment 2(d). (Provide the following information for each additional child: name, date of birth, person with whom the child lived and child’s relationship to the person, address, unless confidential, and dates when the child lived in that place with that person.)
3.	Participation in custody case(s): (check only one)
I HAVE NOT participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitation (parenting time) with any child subject to this case.
I HAVE participated as a party, witness, or in any capacity in any other case, in this or any other state, concerning the custody of or visitation (parenting time) with any child subject to this case. Explain:
a.	Name of each child
b.	Type of case
c.	Court and State
d.	Date of court order or judgment (if any):
4.	Information about custody case(s): (check only one)
I HAVE NO INFORMATION of any cases that could affect the current case, any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations, or adoptions concerning any child subject to this case.
I HAVE THE FOLLOWING INFORMATION concerning cases that could affect the current case, including any cases relating to custody, domestic violence or protection orders, dependency, neglect or abuse allegations, or adoptions concerning any child subject to this case, other than listed in Paragraph 3. Explain:
a.	Name of each child
b.	Type of case
c.	Court and State
d.	Date of court order or judgment (if any):
5.	List all of the criminal convictions including guilty pleas for you and the members of your household for the following offenses: any criminal offense involving acts that resulted in a child being abused or neglected; any offense that is a violation of R.C. 2919.25; any sexually oriented offense as defined in R.C. 2950.01; and any offense involving a victim who was a family or household member at the time of the offense and caused physical harm to the victim during the commission of the offense.
NAME	CASE NUMBER	COURT/STATE/COUNTY	TYPE OF CASE	RESULT OF CASE
6.	Persons not a party to this case:
I DO NOT KNOW OF ANY PERSON who is not a party to this case and who has physical custody or claims to have custody or visitation rights with respect to any child subject to this case.
I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this case has/have physical custody or claim(s) to have custody or visitation rights with respect to any child subject to this case:
a.	Name and address of person
has physical custody claims custody rights claims visitation rights.
Name of each child
b.	Name and address of person
has physical custody claims custody rights claims visitation rights.
Name of each child
c.	Name and address of person
has physical custody claims custody rights claims visitation rights.
Name of each child
7.	I have a continuing duty to inform this Court of any child custody, visitation, parenting time, divorce, dissolution of marriage, separation, neglect, abuse, dependency, guardianship, parentage, termination of parental rights, or domestic violence case concerning the children in this state or in any other state that could affect the current case.
OATH OR AFFIRMATION
I swear or affirm that the answers above are true, complete, and accurate to the best of my knowledge. I understand that making false statements in this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and may also subject me to criminal penalties for perjury under R.C. 2921.11.
DO NOT SIGN THE FORM UNLESS YOU ARE IN FRONT OF THE PERSON WHO WILL NOTARIZE THE PARENTING PROCEEDING AFFIDAVIT FOR YOU
_______________________________________ AFFIANT
Sworn to and subscribed before me on this _________ day of
___________________________, ___________	Sworn to and subscribed before me on this ________day of
________________________________, 2024.
_______________________________________ NOTARY PUBLIC	Pavan Parikh
Clerk of the Common Pleas of Hamilton County, Ohio By _____________________________________ Deputy Clerk