Nebraska Temporary Child Information Affidavit Form

Neb.Rev.Stat. §43-2930 (2008)(1) states that a Temporary Child Information Affidavit shall be offered as
an exhibit by each party to a contested proceeding for a temporary order relating to custody, etc. The
affidavit may include items specified by statute, including those listed below; and others as necessary.
STATE OF NEBRASKA
FORM NO. DC 6:5(8)
Rev. 7/08. Neb. Rev. Stat.
43-2930. REQUIRED.
TEMPORARY
CHILD INFORMATION AFFIDAVIT
CASE NUMBER:
IN THE DISTRICT COURT OF __________________________ COUNTY, NEBRASKA
____________________________,
Plaintiff,
TEMPORARY
CHILD INFORMATION
AFFIDAVIT
vs.
___________________________,
Defendant.
STATE OF NEBRASKA
)
) ss.
COUNTY OF _____________________ )
(county where signed)
I, ______________________________, being first duly sworn, state as follows:
(your full name)
1.
I am the __________________________ in this action.
(plaintiff or defendant)
2.
My spouse/the other parent and I have _______ child(ren). Their names
(circle one)
and years of birth are:
_____________________________________ _________________
(full name of child)
(child’s year of birth)
_____________________________________ _________________
(full name of child)
(child’s year of birth)
_____________________________________ _________________
(full name of child)
(child’s year of birth)
_____________________________________ _________________
(full name of child)
(child’s year of birth)
3.
Following are the names and addresses of all adults with whom the above
child(ren) has/have lived with for the past twelve (12) months:
NAME OF ADULT
ADDRESS
NAME OF CHILD
DATES OF
RESIDENCE
_________________ ___________________ __________________ _____________
(name of adult)
(adult’s address)
(name of child living with adult)
(from mo./yr. to mo./yr.)
_________________ ___________________ __________________ ____________
(name of adult)
(adult’s address)
(name of child living with adult)
(from mo./yr to mo./yr.)
_________________ ___________________ __________________ ____________
(name of adult)
(adult’s address)
(name of child living with adult)
(from mo./yr. to mo.yr.)
_________________ ___________________ __________________ ____________
(name of adult)
4.
(adult’s address)
(name of child living with adult)
(from mo./yr. to mo./yr.)
During the past 12 months, I have provided for the daily needs of the
child(ren) in the following ways:
______________________________________________________________________
(list of daily needs you have provided for the child(ren) in the last 12 months)
______________________________________________________________________
______________________________________________________________________
5.
During the past 12 months, my spouse/the other parent has provided for
(circle one)
the daily needs of the child(ren) in the following ways:
______________________________________________________________________
(list of daily needs your spouse/the other parent has provided for the child(ren) in the last 12 months)
______________________________________________________________________
______________________________________________________________________
6.
During the past 12 months, my work schedule has been as follows:
______________________________________________________________________
(describe your work schedule over the past 12 months)
______________________________________________________________________
______________________________________________________________________
7.
During the past 12 months, my child(ren)’s child care schedule has been
as follows:
______________________________________________________________________
(describe your child(ren)’s child care schedule over the past 12 months)
______________________________________________________________________
______________________________________________________________________
8.
Check the box that applies:
[ ]
At this time, I do not expect a change to my work schedule.
OR
[ ]
At this time, I expect the following change(s) to my work schedule:
__________________________________________________________
(list expected change(s) to your work schedule)
__________________________________________________________
__________________________________________________________
9.
Check the box that applies:
[ ]
At this time, I do not expect a change to my child(ren)’s
child care schedule.
OR
[ ]
At this time, I expect the following change(s) to my child(ren)’s
child care schedule:
________________________________________________________
(list expected change(s) to your child(ren)’s child care schedule)
________________________________________________________
________________________________________________________
10.
Check the box that applies:
[ ]
The child(ren) is/are not involved in any school-related or
extracurricular activites.
OR
[ ]
The child(ren) is/are involved in the following school-related or
extracurricular activities:
PARTY RESPONSIBLE
FOR TRANSPORTATION
ACTIVITY
___________________________________
(activity)
____________________________________
(activity)
____________________________________
(activity)
____________________________________
(activity)
11.
_____________________
(party responsible for transportation)
_____________________
(party responsible for transportation)
_____________________
(party responsible for transportation)
_____________________
(party responsible for transportation)
Check the box that applies:
[ ]
There are no circumstances of child abuse or neglect, domestic
abuse, or unresolved conflict with my spouse/the other parent that
(circle one)
would justify any limitation on custody, parenting time, visitation, or
other access to the child(ren).
OR
[ ]
There are circumstances of child abuse or neglect, domestic abuse,
or unresolved conflict with my spouse/the other parent that would
(circle one)
justify a limitation on custody, parenting time, visitation, or other
access to the child(ren). Following are the details (including details
of any previously filed restraining orders, protection orders, or
criminal no-contact orders):
_____________________________________________________
(list circumstances justifying limitation)
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Dated this ________ day of _________________, _____.
________________________________
(print your name)
________________________________
Signature
________________________________
Street address
________________________________
City, State, ZIP code
________________________________
Telephone number
SUBSCRIBED AND SWORN to before me this _____ day of _______________,
_______.
________________________________
Notary Public
CERTIFICATE OF SERVICE
I hereby certify that on the _______ day of _______________, ______, a true
copy of the foregoing Temporary Child Information Affidavit was sent by first-class mail,
postage prepaid, to my spouse at _________________________________________
(spouse’s address, including street address, city, state, and ZIP code)
_________________________________________________.
________________________________
(your name)