Page 74

15th JUDICIAL DISTRICT COURT

DOCKET NO.:

VEI].SUS

PARISI.I, LOUISIANA ******i.****r,*+**ffi+*d!tt+{:f{!{'.:!:{:{:d:{:{:1:

MANDATORY UCCJEA AFFIDA\/IT FOR CIIILD CUSTODY/\/ISITATION r, (futr

ttame)L"Au d}trrfgfCrftwear

thar rhe rollowing staremerlts are true:

Nanre, birth date ancl sex of eacli child who is involved in this coult case only:

Nalle: Name:

Narle:

errrechilcr(ren)rivingtoday? the chilcl(ren) living today? Wlrere are (1)

Male / Female Male /Fernale

Date of Bir-th: Date of Birth:

Name: Name:

\;cpr

riu " (

q:\.rgrrcssL Lrffiiuzil'C *HL,.",

List all parishes/counties & states whele the child(ren) have lived in the past five (5)

\!/ '-l v

When child(r'en) lived there:

State or Country:

Palish/County:

I

years:

'Z:effe -'?rr';-t

r:ri\ - cLiYv+)\'l (2)

List all persons othel thau you with lvhonr the child(r'en) liave lived in the past five (5) years: Relationship:

Naue;

.thrllPr"Irr"ilt'r

(3)

ll1 /) <-1

I-iave the child(Len) ever been the subject of any of the following l<iuds of cases?

Divolcei Separation CLrstody/Visitation

Child Support

-

''4/

Juvenile Court Child Protection

-,./-*"

AbuseA,leglect

Palental Itights Terutit Adoption

Paternity Protective Order Itestraining Older (4)

If yes, check beloiv:

Other

If you checked yes to # 3 above, auswer the following:

A. l.{ame of Child(r'en): B. Type of Proceeding (custody, visita,tion,

\

{

(-tt

itv"

titt'l

C. Court)Paiish/County & S tate D. Case is still open/on-goiug:

protective ot'der, etc.)

No.;--

r \-C.t-' oocl<et se is riot open/ou-goirtg:

Il' you hnolv of altv person NOT a partv to this proceediils who has physieal custody or claittrs to have custody/visitation liglrts to a child(r'en) listed above, please provide the following:

(5)

-

Narne:

.t{-:\

Addless of Person:

I

IlIr,R.llBY ACI{NOWIEDG]I tltat I hnve a cotrtitttting duty to advise this Court of

conceruing the chiltl(reu) iu this state ol' any other state rvhiclt may affect tlte outcoure of t l'ur:ther rurclerstand that if I knorvingly sweflr or affinn falsely thlt the punisltttteltt may it inrprisonruent. r to and

day

I

of

u

OnL)

J,-- **,1',.ilH'1i'g?.x:Fl"un''

0?1

BergeronvsBergeron Court minutes  

Court minutes 2009-2010

BergeronvsBergeron Court minutes  

Court minutes 2009-2010

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