Form JD-FM-164 "Affidavit Concerning Children" - Connecticut

What Is Form JD-FM-164?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-FM-164 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-FM-164 "Affidavit Concerning Children" - Connecticut

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STATE OF CONNECTICUT
AFFIDAVIT CONCERNING
SUPERIOR COURT
CHILDREN
COURT OF PROBATE
JD-FM-164
Rev. 2-15
Court Use Only
Instructions
www.jud.ct.gov
C.G.S. § 46b-115s
AFFACUS
P.B. § 25-57
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
*AFFACUS*
sign and date the affidavit.
Judicial District of
At (Town)
Probate District name and number
Docket number
Plaintiff/Applicant's (Last, first, middle initial)
Defendant/Respondent's (Last, first, middle initial)
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.
Child's name (First, middle, last)
Date of birth (Month, day, year)
Place of residence
Name(s) and present address(es) of
Relationship
Date(s) of residence
(Town or city, and state, unless
person(s) child lived with
to child
confidential by court order)
(unless confidential)
From
To
The present
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(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)
Place of residence
Name(s) and present address(es) of
Relationship
Date(s) of residence
(Town or city, and state, unless
person(s) child lived with
to child
confidential by court order)
(unless confidential)
From
To
The present
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(date)
(date)
Check here if additional children are listed on JD-FM-164A.
Page 1 of 2
Print Form
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STATE OF CONNECTICUT
AFFIDAVIT CONCERNING
SUPERIOR COURT
CHILDREN
COURT OF PROBATE
JD-FM-164
Rev. 2-15
Court Use Only
Instructions
www.jud.ct.gov
C.G.S. § 46b-115s
AFFACUS
P.B. § 25-57
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
*AFFACUS*
sign and date the affidavit.
Judicial District of
At (Town)
Probate District name and number
Docket number
Plaintiff/Applicant's (Last, first, middle initial)
Defendant/Respondent's (Last, first, middle initial)
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.
Child's name (First, middle, last)
Date of birth (Month, day, year)
Place of residence
Name(s) and present address(es) of
Relationship
Date(s) of residence
(Town or city, and state, unless
person(s) child lived with
to child
confidential by court order)
(unless confidential)
From
To
The present
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(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)
Place of residence
Name(s) and present address(es) of
Relationship
Date(s) of residence
(Town or city, and state, unless
person(s) child lived with
to child
confidential by court order)
(unless confidential)
From
To
The present
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(date)
(date)
From
To
(date)
(date)
Check here if additional children are listed on JD-FM-164A.
Page 1 of 2
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1. (Check one)
I have
I have not
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
checked "I have," give the name of the court, the court case number and the date of the decision in the case or cases:
(Check item 2 or 3 below)
2.
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.
3.
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.
Case name
Docket number
Court location (Including state)
Nature of proceeding
Case name
Docket number
Court location (Including state)
Nature of proceeding
4. (Check one)
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:
Name:
Address:
(unless confidential)
5. The mother of the child(ren) named in the Complaint or Application is pregnant.
Yes
No
Do not know
6. A child has been born to the mother named in the Complaint or Application after the filing of the Complaint or Application.
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
Signature
Date signed
Sworn to before me (Assistant Clerk/Commissioner of Superior Court/Notary Public)
JD-FM-164
Rev. 2-15
Page 2 of 2
ADA NOTICE
You must tell the court about any case in Connecticut or
The Judicial Branch of the State of
Connecticut
complies
with
the
another state that could affect this case, if you learn about
Americans with Disabilities Act (ADA). If
it during this case.
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.
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