How to Fill Out Affidavit Concerning Children (JD-FM-164)

The Affidavit Concerning Children (JD-FM-164) is a mandatory, sworn legal document required in all Connecticut family law cases involving minor children, including divorce, legal separation, and custody actions. Its primary purpose is to provide the court with detailed information about each child's living situation for the past five years. This information is crucial for the court to determine if it has the legal authority, or 'jurisdiction,' to make decisions about your children's custody and welfare.

This form is based on a uniform state law called the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA), codified in Connecticut General Statutes (C.G.S.) § 46b-115s. The UCCJEA prevents parents from moving to another state simply to find a court that might be more favorable to their custody claims. By providing a complete five-year history, you are helping the judge establish the child's 'home state' and confirm that the Connecticut court is the proper venue for your case.

Because this is an affidavit, you are swearing under oath that the information you provide is true and accurate to the best of your knowledge. It must be signed in the presence of a notary public, a court clerk, or a Commissioner of the Superior Court. Filing an incomplete or inaccurate affidavit can delay your case or have other legal consequences, so it's essential to fill it out carefully and completely.

Requirements

Before you begin filling out the JD-FM-164 form, gather the following documents and information to ensure accuracy and save time:

• Case Information: Your court case docket number, the Judicial District, and the full names of the Plaintiff/Applicant and Defendant/Respondent. This can be found on your Summons (JD-FM-3) or Complaint (JD-FM-159).
• Children's Personal Information: The full legal name and date of birth for each minor child involved in the case. A copy of each child's birth certificate is the best source for this.
• Children's 5-Year Residence History: For each child, you need a complete list of every address where they have lived for the past five years. For each residence, you will need:
  • The start and end dates of their stay.
  • The city and state.
  • The full name and current address of the adult(s) they lived with at that location.
  • The relationship of that adult to the child (e.g., Mother, Father, Grandparent).
  • Helpful Documents: School enrollment records, medical records, old lease agreements, utility bills, or tax returns can help you accurately reconstruct this timeline.
• Prior Court Case Information: Details of any other court case (in Connecticut or any other state) where you were a party or witness concerning the custody or visitation of your children. You will need the case name, docket number, and the court where it was heard.
• Other Relevant Case Information: Information about any other civil or criminal cases that could affect your current case, such as those involving domestic violence, protective orders, child neglect (DCF involvement), or guardianship. You'll need the case details for these as well.

Step-by-Step Instructions

Case Caption and Party Information

This top section of the form identifies your specific case and the parties involved. This information must match all other documents filed in your case.

Judicial District of: Enter the name of the Judicial District where your case is being heard (e.g., Stamford/Norwalk, Hartford, New Haven). Example: Fairfield

At (Town): Enter the town where the courthouse is located. Example: Bridgeport

Probate District name and number: Only fill this out if your case is in Probate Court. If it's in Superior Court for a divorce or custody case, you can leave this blank. Example: Norwalk-Wilton PC 49

Docket number: Enter the unique number assigned to your case by the court clerk. This number appears on all official court documents for your case. Example: FBT-FA24-1234567-S

Plaintiff/Applicant's name (Last, first, middle initial): Enter the full name of the person who started the court case (the Plaintiff or Applicant). Example: Doe, Jane M.

Defendant/Respondent's name (Last, first, middle initial): Enter the full name of the person responding to the court case (the Defendant or Respondent). Example: Doe, John A.

Children's 5-Year Residence History

This is the most critical section of the form. You must provide a complete residence history for the last five years for each child. Start with the child's current residence and work backward in time, creating a new entry for each time the child moved. If you have more than two children, you must use the Addendum form (JD-FM-164A).

Child's name (First, middle, last): Enter the child's full legal name.

Date of birth (Month, day, year): Enter the child's date of birth in MM/DD/YYYY format.

Date(s) of residence - From / To The present: For the child's current address, enter the date they moved in under 'From (date)'. The 'To' field is pre-filled as 'The present'. Example: From: 06/15/2022 To: The present

Date(s) of residence - From / To (Past Residences): For all previous residences within the last five years, enter the move-in date under 'From' and the move-out date under 'To'. Ensure there are no gaps in time. Example: From: 08/01/2019 To: 06/14/2022

Place of residence (Town or city, and state, unless confidential by court order): Enter the town/city and state for each period of residence. You do not need the full street address here. Example: Stamford, CT ⚠️ If a court has issued a protective order allowing an address to be kept confidential for safety, write 'Confidential per court order' instead of the location.

Name(s) and present address(es) of person(s) child lived with (unless confidential): List the full name and CURRENT full mailing address of each adult the child lived with during that time period. This must be their current address, not the address where they lived with the child. Example: Jane M. Doe, 123 Main St, Anytown, CT 06902 ⚠️ If an adult's address is protected by a court order, write 'Confidential per court order'.

Relationship to child: State the relationship of the person(s) listed to the child. Example: Mother

Residence information is same as for child above.: If your second child has the exact same five-year residence history as the first child you listed, you can check this box to avoid re-writing the information.

Select here if additional children are listed on JD-FM-164A.: If you have more than two minor children, you must complete and attach form JD-FM-164A. Check this box to indicate that you have attached the addendum.

History of Other Court Cases

This section asks about your involvement and knowledge of other legal proceedings that could be relevant to the court's decisions about your children.

(Select 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.: Check 'I have' if you have ever been part of another court case about custody or visitation for any of the children on this form. This includes being the plaintiff, defendant, or even just a witness. If you check 'I have,' you must provide the court name, case number, and date of the decision in the space provided.

(Select item 2 or 3 below): You must select either item 2 or 3. Check item 2 ('I do not know...') if you are unaware of any other cases. Check item 3 ('I know of the following...') if you know about any other civil or criminal cases that could affect this one. This includes cases for domestic violence, protective orders, guardianship, child neglect (DCF), termination of parental rights, or adoption. If you check item 3, you must complete the table with all relevant case information. ⚠️ Be thorough. Failing to disclose a relevant case, especially one involving child safety like a protective order or DCF action, can be viewed very negatively by the court.

Custody Claims and Family Changes

These questions address who currently has custody and whether there have been any recent changes to the family structure, such as a new baby.

(Select one) No one except the plaintiff/applicant and defendant/respondent has physical custody or claims to have custody or visitation rights... OR The following person(s) has physical custody or claims to have custody...: Select the first option if only you and the other parent have or are seeking custody. Select the second option if another person (like a grandparent, aunt, or uncle) currently has physical custody of a child or is legally claiming custody/visitation rights. If you select the second option, provide their full name and address.

The parent of the child(ren) named in the Complaint or Application is pregnant.: Check 'Yes', 'No', or 'Do not know' to indicate if the parent is currently pregnant. This is relevant for future custody and support orders.

A child has been born to the parent named in the Complaint or Application after the filing of the Complaint or Application.: Check 'Yes' if a child was born to the parent since the case was first filed. If 'Yes', provide the new child's name and date of birth. This ensures the new child can be included in the court's orders.

Signature and Notarization

This is the final step to make your form a legally binding affidavit. It must be done correctly for the court to accept the document.

Signature: Sign your name on this line ONLY when you are physically in front of a notary public, court clerk, or Commissioner of the Superior Court. ⚠️ DO NOT SIGN THIS FORM AHEAD OF TIME. Your signature must be witnessed by the official. Signing it beforehand will invalidate the form, and you will have to do it all over again.

Print name of person signing: Neatly print your full name.

Date signed: Write the date you are signing the form in front of the official.

Sworn to before me (Assistant Clerk/Commissioner of Superior Court/Notary Public): This section is for the official to complete. They will sign, date, and (if applicable) stamp the form to certify that you swore to the truth of its contents in their presence.

Common Mistakes to Avoid

1. Signing the Form Too Early: The most common mistake is signing the affidavit before you are in the presence of a notary or court clerk. This invalidates the document.
2. Incomplete 5-Year History: Failing to account for the entire 5-year period for each child, or leaving gaps in the timeline. The history must be continuous.
3. Forgetting to Disclose Other Cases: Neglecting to list all relevant court cases, especially those involving DCF, protective orders, or criminal matters. This can damage your credibility with the judge.
4. Not Using the Addendum (JD-FM-164A): If you have more than two children, you must use the addendum form. Squeezing three children onto the main form will result in it being rejected.
5. Incorrect Party Information: Listing the Plaintiff and Defendant in the wrong boxes. Double-check your original Complaint to be sure.
6. Listing Old Addresses for People: In the residence history section, you must list the current address of the person the child lived with, not the address where they lived together in the past.

Frequently Asked Questions

What is the UCCJEA and why does the form ask for five years of residence history? The UCCJEA (Uniform Child Custody Jurisdiction and Enforcement Act) is a law adopted by nearly all states, including Connecticut, to create consistency in custody cases. It helps determine a child's 'home state'—usually where the child has lived for the six months prior to the case starting. The five-year residence history gives the court a comprehensive picture to confirm that Connecticut is the correct state to make custody decisions and to prevent parents from moving to another state to seek a more favorable outcome ('forum shopping').

What if I can't remember an exact address or date from four years ago? Do your best to be as accurate as possible. Use old records like school registrations, tax returns, or emails to pinpoint dates and locations. If you absolutely cannot find a precise street address, provide the city and state and be prepared to explain to the judge the steps you took to find the information. Honesty and a good-faith effort are more important than perfection. Never knowingly provide false information.

My ex and I agree on custody. Do I still need to fill out this form? Yes, absolutely. The JD-FM-164 is a mandatory form in every Connecticut family case involving minor children, regardless of whether the parents are in agreement. The court must independently verify that it has jurisdiction over the children before it can approve your custody agreement and issue official orders.

What does 'unless confidential by court order' mean for an address? This applies in situations where there is a history of domestic violence and a court has issued a protective or restraining order. These orders often include a provision that allows a victim's address to be kept confidential for their safety. If such an order exists for you or your child, you should write 'Confidential per court order' or 'Address confidential pursuant to protective order' instead of listing the physical address.

Next Steps

Once you have completely filled out and notarized your Affidavit Concerning Children (JD-FM-164), you must file it with the court and provide a copy to the other party. Follow these steps:

1. Make Copies: After the form is signed and notarized, make at least two photocopies. The original is for the court, one copy is for the other party, and one is for your personal records.
2. File with the Court: Take the original, signed, and notarized form to the Superior Court Clerk's office in the Judicial District where your case is filed. The clerk will stamp it and place it in your official case file.
3. Serve the Other Party: You must send one full copy of the filed affidavit to the other party or their attorney. This is called 'service.' Follow the court rules for proper service, which may include in-person delivery, mail, or e-service if applicable.
4. Keep Your Copy: Keep a copy of the filed and stamped form with all your other important legal documents.

This affidavit is a foundational document. The judge will review it at the beginning of your case and may refer to it during hearings or at the final trial to make decisions about your children.