Plaintiff’s name

In the matter of 
 

Defendant’s name

v

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

2. The Cities/States/Countries the child(ren) have lived in during the last 5 years along with the dates the child(ren) lived 
 

there (include addresses if available):

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.

Approved, SCAO
Form MC 416, Rev. 7/22
MCL 722.1206, MCL 722.1209
Page 1 of 2

Distribute form to: 
Court 
FOC (if applicable) 
Defendant/Respondent
Plaintiff/Petitioner

STATE OF MICHIGANJUDICIAL CIRCUITPROBATE COURTCOUNTYUNIFORM CHILD CUSTODY JURISDICTIONENFORCEMENT ACT AFFIDAVITCASE NO. and JUDGECourt address                     Court telephone no.     Uniform Child Custody Jurisdiction Enforcement Act Affidavit 
Page 2 of 2

(7/22) 

Case No. 
 

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 
 
 

 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

 

 is continuing. 

 

 has been stayed by the court.

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.

7. The child(ren)’s “home state” is 
 

 . *See definition of “home state” below.

 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 affiant

Name of affiant (type or print)

Address of affiant

    

     

Subscribed and sworn to before me on 
 

                     

Date

 

 

 

 

 

 

 

 

My commission expires on 
 
Notary public, State of Michigan, County of 

                     

 

 

Deputy clerk/Notary public signature

 . 

Name (type or print)
 

 

 . 

 Acting in the County of 

 

 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. MCL 722.1102(g).