(c) A document substantially in the following form may be used to create a pleading and affidavit for purposes of paragraph (1) of subsection (d) of this Code section: "IN THE COURT OF COUNTY STATE OF GEORGIA A.B., ) Plaintiff ) ) v. ) Civil Action ) File no. C.D., ) Defendant ) COMPLAINT
The defendant C.D., herein named, is a resident of (street), , (city) County, Georgia, and is subject to the jurisdiction of this court.
As of (date), Plaintiff can fully demonstrate to the court that he or she:
(1) Has fully and completely undertaken a permanent, unequivocal, committed, and responsible parental role in the child's life;
(2) Engaged in consistent caretaking of the child;
(3) Established a bonded and dependent relationship with the child, which relationship was fostered or supported by a parent of the child, and Plaintiff and the parent have understood, acknowledged, or accepted that or behaved as though Plaintiff is a parent of the child; and
(4) Accepted full and permanent responsibilities as a parent of the child without expectation of financial compensation.
The facts of the case are:
1. 2. 3. 4. Dated Pro Se Applicant Address Address (CERTIFICATE OF SERVICE)" "AFFIDAVIT OF PETITIONER STATE OF GEORGIA COUNTY OF Personally appeared before me, the undersigned officer duly authorized to administer oaths, , who, after having been sworn, deposes, and says as follows: That my name is: That my address is: These are the facts to support the existence of an equitable caregiver relationship with a child as set forth in subsection (c) of O.C.G.A. 19-7-3.1: Dated Pro Se Applicant Address Address Sworn to and subscribed before me this day of , . Notary public (SEAL) My commission expires: "