Form Mc 416 – Fill Out and Use This PDF

CASE NAME:

1.The name and present address of each child (under 18) in this case is:

2.The addresses where the child(ren) has/have lived within the last 5 years are:

3.The name(s) and present address(es) of custodians with whom the child(ren) has/have lived within the last 5 years are:

4.I do not know of, and have not participated (as a party, witness, or in any other capacity) in any other court decision, order, or proceeding (including divorce, separate maintenance, separation, neglect, abuse, dependency, guardianship, paternity, termination of parental rights, and protection from domestic violence) concerning the custody or parenting time of the child(ren), in this state or any other state, except: Specify case name and number, court name and address, and date of child

custody determination, if one.

5.I do not know of any pending proceeding that could affect the current child custody proceeding, including a proceeding for enforcement or a proceeding relating to domestic violence, a protective order, termination of parental rights, or adoption, in this state or any other state, except: Specify case name and number, court name and address, and nature of the proceeding.

That proceeding    is continuing.    has been stayed by the court.

Temporary action by this court is necessary to protect the child(ren) because the child(ren) has/have been subjected to or threatened with mistreatment or abuse or is/are otherwise neglected or dependent. Attach explanation.

6.I do not know of any person who is not already a party to this proceeding who has physical custody of, or who claims rights of legal or physical custody of, or parenting time with, the child(ren), except: State name(s) and address(es) of each person.

8. I state that a party’s or child’s health, safety, or liberty would be put at risk by the disclosure of this identifying information.

I have filled this form out completely, and I acknowledge a continuing duty to advise this court of any proceeding in this state or any other state that could affect the current child-custody proceeding.

Signature of affiantName of affiant (type or print)Address of affiant

This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.

“Home state” means the state in which the child(ren) lived with a parent or a person acting as a parent for at least 6 consecutive months immediately before the commencement of a child-custody proceeding. In the case of a child less than 6 months of age, the term means the state in which the child lived from birth with a parent or person acting as a parent. A period of temporary absence of a parent or person acting as a parent is included as part of the period.