COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

:	Enter
Plaintiff/Petitioner	:	Date
:	Case No.
File No.
-vs/and-	:	CSEA No.
Judge
:
Defendant/Petitioner

AFFIDAVIT IN COMPLIANCE WITH	3127.23 OF THE OHIO REVISED	CODE

discloses the following information under oath and represents that it is true to the best of his/her knowledge and belief based upon what is reasonably ascertainable:

1. I am requesting the court to not disclose my address or that of the children named below. I am claiming that my address is confidential pursuant to Ohio Revised Code 3127.23(D) and should be placed under seal in that the health, safety, or liberty of myself and/or the children would be jeopardized by the disclosure of the identifying information. I understand that a hearing will be held to determine whether the information can be disclosed based on my claim.

2. The name(s) and the present address(es), or the whereabouts, of the children involved are:

1	DOB:	Present Address
2	DOB:	Present Address
3	DOB:	Present Address
4	DOB:	Present Address

3. The children have lived at the following address(es) during the last 5 years:

Prior Addresses:

4.	The name(s) and present address(es) of all persons with whom the children have lived during	the past 5 years are:

Names	Address(es)

5.	I have/have not participated as a party, witness, or in any way in some court action in this or	another state concerning the custody, support, care of or visitation or parenting time with these	same children.

If I circled that I participated, I have listed below the court, the case number and kind of case:

Case Number	Name of Court	Kind of Case

6.	I do/do not know of any proceedings that could affect this proceeding, including proceedings for	enforcement of child custody determinations, relating to domestic violence or protection orders,	to adjudicate the children as an abused, neglected or dependent children, seeking termination of	parental rights or adoptions. If I do know, I have listed the information here:

7.	The following person(s) are not parties to this case and (A) have physical custody of the	children or (B) claim to be a parent of the children or (C) claim to have custody, visitation or	parenting time rights regarding the children. (If none, write “None” on a line below)

Name	Address	State reason: A, B or C	from above

Name	Addresss	State reason: A, B or C

8.	By signing below, I understand that I have a duty to inform the court if I get any information	about any parenting proceeding or court case filed in another court about these same children	that may affect this proceeding.

Signature

Sworn to before me and subscribed in my presence this ______ day of _______________________, 20______.

Notary Public