Family Court Affidavit Form #3 - Greene County, Missouri

IN THE CIRCUIT COURT OF GREENE COUNTY, MISSOURI
FAMILY COURT DIVISION
_______________________ [name of minor child] )
by Next Friend __________________________ )
SSN: ___________________ )
and )
_________________________, individually, )
SSN: ____________________ )
Plaintiff(s), )
)
vs. ) Case No.________________
)
_________________________, )
SSN: ____________________ )
and )
______________________ [name of minor child] )
SSN: ____________________ )
by Next Friend _________________ )
SSN: ___________________ )
Defendant(s) )
AFFIDAVIT IN SUPPORT OF JUDGMENT
PURSUANT TO THE UNIFORM PARENTAGE ACT
(Form #3)
The undersigned, having first been sworn upon his/her oath, hereby swears/affirms pursuant to local
rule 2.3 that the following testimony is true:
1. My name is ___________________ and I am the (Plaintiff)(Defendant) in the above action for the
determination of parent-child relationship.
2. I currently reside at _____________________ [street address] in ____________ County, State of
______________. I (am)(am not) acting as Next Friend for the minor child.
3. The minor child is a (male)(female) who was born on _______________ [date] in _____________,
_____________ [city & state] and the birth of the child is recorded in the Bureau of Vital Statistics
of the State of Missouri.
4. (Plaintiff)(Defendant) is the biological mother of the child and resides at
______________________ [address] in ___________ County, ____________ [state].
5. The minor child is presently residing with (Plaintiff)(Defendant) at _________________,
________________ [city & state] and has lived in the state of Missouri for six (6) months
preceding the filing of the Petition.
6. Neither Plaintiff nor Defendant has participated in any capacity in any other litigation concerning
______/_______
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form last revised February 26, 2013

the custody of the minor child in this or any other state. I do not have any information of any other
custody proceeding concerning the minor child pending in any court of this state or any other state
and I am unaware of any other person not a party to this proceeding who has physical custody or
claims to have custody or visitation rights with respect to the minor child.
7. That the (Plaintiff)(Defendant) and I engaged in sexual intercourse with each other during the
months of ______________________ [months & years] and as a result of such intercourse,
(Plaintiff)(Defendant) gave birth to the child at issue herein on _______________ [date] in
_______________ [city], Missouri.
8. This Court has personal jurisdiction in this action because (circle those applicable):
1. the parties had sexual intercourse in this state and submit to the jurisdiction of the Court, or
2. by personal service of the summons outside of the state, or
3. by certified mail with proof of actual receipt, or
4. other method allowed by court rule or statute consistent with the requirements of the
constitution of the State of Missouri and/or the constitution of the United States.
9. Greene County is the proper venue for this action because (circle those applicable);
1. the child resides in Greene County, or
2. the mother resides in Greene County, or
3. the father resides in Greene County or may be found in Greene County.
10. The father named herein is presumed to be the father of the minor child because (circle those
applicable):
1. the father and mother were married and the child was born during the marriage or within
300 days after the marriage was terminated by death, annulment, declaration of invalidity, or
dissolution of marriage, or
2. the father and mother attempted to marry before the birth of the child although the attempted
marriage is or may be declared invalid, or
3. the father and mother married or attempted to marry after the child was born and the father
acknowledged paternity of the child in writing and filed the same with the Bureau of Vital
Statistics, or
4. the father was named with his consent as the father on the child's birth certificate, or
5. scientific testing indicates the father is not excluded as such and that probability of paternity
is 98% or higher.
11. The father (has)(has not) signed an acknowledgement of paternity and upon the signing of the
acknowledgement thereafter filed the same with the Bureau of Vital Statistics.
12. The Plaintiff and Defendant have agreed to a Parenting Plan concerning custody and visitation and
no domestic violence has occurred and the minor child at issue herein has not been a victim of a
sexual offense as defined under Chapter 566 of the Revised Statutes of Missouri or any offense
defined under Chapter 568 RSMo. concerning violence against family members and the attached
Parenting Plan is in the best interests of the minor child.
13. More than 30 days have elapsed since Defendant was duly served with process or voluntarily
entered his/her appearance in the case.
______/_______
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form last revised February 26, 2013

14. Defendant is in default or the parties have entered into a written settlement.
15. It is in the best interest of the minor child that custody be awarded as follows (check one):
___ That the parties be awarded joint legal custody and that (Plaintiff)(Defendant) be awarded
primary physical custody in accordance with the terms of the Parenting Plan attached hereto.
___ That the parties be awarded joint legal and physical custody in accordance with the terms of the
Parenting Plan attached hereto.
16. Support for the minor child is required and has been calculated according to Form 14 and a
Parenting Plan and Form 14 calculation are attached hereto as exhibits ___________.
(check one of the following):
___ The presumed amount of child support based on the Form 14 calculation is not rebutted as
unjust or inappropriate and that presumed amount of child support is set forth in the proposed
Judgment.
___ The presumed amount of child support based on the Form 14 calculation is rebutted as unjust or
inappropriate and the Court should depart (upward/downward) from the Form 14 presumed amount
to that amount set forth in the proposed Judgment for the following reason(s):
_____________________________________________________________________________
______________________________________________________________________________
17. The parties have agreed that (Plaintiff)(Defendant) is to provide medical, dental, prescription,
counseling and optical coverage for the minor child and the parties have further agreed that
(Plaintiff)(Defendant) shall pay ____% of all amounts not covered for medical, dental, prescription,
counseling, and optical expenses not covered by insurance (including any co-payments) and
(Plaintiff)(Defendant) shall pay the other ____% of said uncovered expenses.
18. The birth certificate of the minor child needs to be amended by the Bureau of Vital Statistics to
reflect that (Plaintiff)(Defendant) is the father of the minor child. [strike this paragraph if not
applicable]
19. The name of the minor child should be changed to ___________________. [strike if not applicable
or desired]
20. (Plaintiff)(Defendant) has agreed to pay the court costs of this action and/or scientific testing and/or
guardian ad litem fees.
21. Both parents have completed a court-approved parent education program and have filed their
certificates of completion with the Court.
22. At least one of the parties hereto is represented by legal counsel.
______/_______
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form last revised February 26, 2013

_______________________
Plaintiff
STATE OF MISSOURI )
) ss.
COUNTY OF GREENE )
Subscribed and sworn before me this ____ day of ________, 20___.
My commission expires:
Notary Public
_________________________
Attorney for Plaintiff (if any)
___________________________
Defendant
STATE OF MISSOURI )
) ss.
COUNTY OF GREENE )
Subscribed and sworn before me this ____ day of _____, 20____.
My commission expires:
Notary Public
__________________________
Attorney for Defendant (if any)
Submitted to the Court this _________ day of ____________________, 20_____.
_______________________
Circuit Judge
C:\My Documents\Family Court Affidavit Form #3.doc
______/_______
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form last revised February 26, 2013