ADDENDUM TO AFFIDAVIT CONCERNING CHILDREN
JD-FM-164A Rev. 11-01 C.G.S. § 46b-115S, P.B. § 25-57 CHILD'S NAME (First, middle, last)
STATE OF CONNECTICUT SUPERIOR COURT
(Use this form to list additional children to form JD-FM-164)
DATE OF BIRTH (Mo, day, yr) LOCATION (Town or city, and state, unless confidential) DOCKET NO.
RESIDENCE INFORMATION IS SAME AS FOR PREVIOUS CHILD (If not same, provide information) RELATIONSHIP TO CHILD
DATE(S) OF RESIDENCE
NAME(S) AND PRESENT ADDRESS(ES) OF PERSON(S) CHILD LIVED WITH (UNLESS CONFIDENTIAL)
TO THE PRESENT
TO
TO
TO
TO CHILD'S NAME (First, middle, last) DATE OF BIRTH (Mo, day, yr) LOCATION (Town or city, and state, unless confidential) RESIDENCE INFORMATION IS SAME AS FOR CHILD ABOVE (If not same, provide information) RELATIONSHIP TO CHILD
DATE(S) OF RESIDENCE
NAME(S) AND PRESENT ADDRESS(ES) OF PERSON(S) CHILD LIVED WITH (UNLESS CONFIDENTIAL)
TO THE PRESENT
TO
TO
TO
TO CHILD'S NAME (First, middle, last) DATE OF BIRTH (Mo, day, yr) LOCATION (Town or city, and state, unless confidential) RESIDENCE INFORMATION IS SAME AS FOR CHILD ABOVE (If not same, provide information) RELATIONSHIP TO CHILD
DATE(S) OF RESIDENCE
NAME(S) AND PRESENT ADDRESS(ES) OF PERSON(S) CHILD LIVED WITH (UNLESS CONFIDENTIAL)
TO THE PRESENT
TO
TO
TO
TO
(Continued...)
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CHILD'S NAME (First, middle, last)
DATE OF BIRTH (Mo, day, yr) LOCATION (Town or city, and state, unless confidential)
RESIDENCE INFORMATION IS SAME AS FOR PREVIOUS CHILD (If not same, provide information) RELATIONSHIP TO CHILD
DATE(S) OF RESIDENCE
NAME(S) AND PRESENT ADDRESS(ES) OF PERSON(S) CHILD LIVED WITH (UNLESS CONFIDENTIAL)
TO THE PRESENT
TO
TO
TO
TO CHILD'S NAME (First, middle, last) DATE OF BIRTH (Mo, day, yr) LOCATION (Town or city, and state, unless confidential) RESIDENCE INFORMATION IS SAME AS FOR CHILD ABOVE (If not same, provide information) RELATIONSHIP TO CHILD
DATE(S) OF RESIDENCE
NAME(S) AND PRESENT ADDRESS(ES) OF PERSON(S) CHILD LIVED WITH (UNLESS CONFIDENTIAL)
TO THE PRESENT
TO
TO
TO
TO CHILD'S NAME (First, middle, last) DATE OF BIRTH (Mo, day, yr) LOCATION (Town or city, and state, unless confidential) RESIDENCE INFORMATION IS SAME AS FOR CHILD ABOVE (If not same, provide information) RELATIONSHIP TO CHILD
DATE(S) OF RESIDENCE
NAME(S) AND PRESENT ADDRESS(ES) OF PERSON(S) CHILD LIVED WITH (UNLESS CONFIDENTIAL)
TO THE PRESENT
TO
TO
TO
TO JD-FM-164A (Back) Rev. 11-01
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