AFFIDAVIT OF CRIMINAL HISTORY                                                                                                                                       11
I, / We, __________________________________________ and __________________________________________ affirm, under the penalties of perjury, that I have never been arrested for, or convicted of, any of the following offenses:
 
Murder (IC 3542-1-I).
Causing suicide (IC 35-42-1-2).
Assisting suicide (IC 35-42-1-2.5).
Voluntary manslaughter (IC 35-42-1-3).
Reckless homicide (IC 3542-1-5).
Battery as a felony (IC 35-42-2-1).
Aggravated battery (IC 35-42-2-1.5).
Kidnapping (IC 35-42-3-2).
Criminal confinement (IC 3542-3-3).
A felony sex offense under IC 35424).
Carjacking (IC 35-42-5-2).
Arson (IC 3543-1-1).
Incest (IC 35-46-1-3).
Neglect of a dependent (IC 3546-14(a)(l) and IC 35-46-l-4(a)(2)).
Child selling (IC 35-46-1-4(b)).
A felony involving a weapon under IC 3547.
A felony relating to controlled substances under IC 35484.
An offense relating to material or a performance that is harmful to minors or obscene under IC 3549-3.
A felony that is substantially equivalent to a felony listed in subdivisions (1) through (18) for which the conviction was entered in another state.
I am submitting this affidavit, pursuant to IC 31-19-11-1 for the following reason: Check One)
Petition has been filed regarding the adoption of a minor child.
Order has been filed regarding custody or guardianship of a minor child.
Adult wishing to have a child placed in their care.
 Signature of Applicant A
 Signature of Applicant B
 Street:
 City, State, Zip:
 State of ________:
 Country of:
SUBSCRIBED AND SWORN to before me, a Notary Public, in and for said County and State, this (day) of
(date).
 My Commission Expires:
Notary Public County of Residence:
 
Prepared by:

Embryos Alive
Cincinnati, Ohio 45242
513-518-7006 bb@cinci.rr.com
www.EmbryosAlive.com