1 In re the Application of:
2 Petitioner:
3 and
4 Respondent:
5 STATEMENT OF RESIDENCE OF A MINOR CHILD
The Convention on the Civil Aspects of International Child
6 Abduction, done at the Hague on 25 Oct 1980
[International Child Abduction Remedies Act, 42 U.S.C. 11601 et
7 seq]
8 1.0 NAME AND DATE OF BIRTH OF CHILD
9 1.1 Name and first names of child:
10 1.2 Date and place of birth:
11 1.3 Passport or identity card No., if any:
12 1.4 Nationality of child:
13 2.0 RESIDENCE OF CHILD
14 Period of Residence (From - To):
15 Number of Days:
16 Purpose (eg, domicile, visit, etc):
17 Address of Child:
18 Person Child Lived With
19 (Name and Present Address):
20 Relationship to Child:
21 [Repeat the above for each period of residence]
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1 3.0 VERIFICATION (--Optional--)
2 3.1 I am the attorney for the Petitioner; I make this
3 verification on behalf of the Petitioner because
4 Petitioner is absent from (county and state); the above
5 document is true of my own knowledge, except as to the
6 matters that are stated in it on my information and
7 belief and as to those matters I believe it to be true.
8 I declare under penalty of perjury under the laws of the
9 State of (State) that the foregoing is true and correct.
10 Executed on (date signed) at (place signed).
11 _______________________
Attorney for Petitioner
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