AFFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER
OR CUSTODY PROCEEDINGS
Name of
Pursuant to Trial Court Rule IV Case:
Boston District Court Juvenile Court Probate & Family Court Superior Court
Municipal
Court Division Division Division Division
Section
1
I, , hereby declare, to the best of my knowledge, information and belief that all the information
on this form is true and complete:
The name(s) of the child(ren) whose care or custody is at issue is (are):
A. , B. , C. ,
(LAST, FIRST) (LAST, FIRST) (LAST, FIRST)
Section
2
Use only the letter appearing in front of the child’s name above when referring to that child when completing the remaining sections.
Section
3
The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered persons
and their dependent child(ren), or the party filing this affidavit believes that he/she or the child(ren) is/are in danger of physical or
emotional abuse, or the party is filing an action under G.L.c. 209A. If you believe that this provision applies to you, check box
at right, complete sections 10 and 11 on the reverse side of this page and DO NOT complete sections 4 and 5 below.
The address(es) of the above-named child(ren) whose care or custody is at issue in this case is/are:
Address(es) Address(es) During Last 2 Years, If Different
CHILD A.
CHILD B.
CHILD C.
Section
4
My address is:
Section
5
Section
6
I have have not participated in and I know do not know of other care or custody proceedings involving the above-
named child(ren) in Massachusetts or in any other state or country.
Certified copies of any pleadings or determinations in a care or custody proceeding outside of Massachusetts listed in sections 7 and 8 must be filed
with this affidavit unless already filed with this court or an extension for filing these documents has been granted by this court.
The following is a list of all pending or concluded proceedings I have participated in or know of involving the care or custody of the above-
named child(ren):
[W]itness
Letter
of
Child
Court Docket No. Status of Case
(Custody awarded to)
(Date of award)
[P]arty
[O]ther
[N]one
CHILD [ ]
CHILD [ ]
CHILD [ ]
Section
7
The names and addresses of parties to care or custody proceedings involving (any of) the above-named child(ren) or those claiming a
legal right to this (these) child(ren) during the last two years (not including myself) are:
Letter of Child Name of Party/Claimant Current (or last known) Address of Party/Claimant
CHILD
CHILD
CHILD
Section
8
Section
9
If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-
named child(ren) and I am requesting the court to impound this affidavit. See instructions.
This affidavit must be personally signed by the party listed in section 1 above, unless he/she is under 18 years of age or has been adjudged incompetent, in
which case the attorney of record must sign. A revised affidavit must be filed with the court if new information is discovered subsequent to this filing.
Signed this ____________ day of ________________________________, 20 ____, under the penalties of perjury.
X
SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE PRINTED NAME OF PERSON SIGNING
ADDRESS OF ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE
C
COURT
’
S COPY
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.
OCAJ-1 TCR IV (2/93) c.g.f. / LRAM
ADDRESSES TO BE KEPT CONFIDENTIAL
The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered persons
and their dependent child(ren), or the party filing this affidavit believes that he/she or the child(ren) is/are in danger of physical or
emotional abuse, or the party is filing an action under G.L.c. 209A. If you believe that this provision applies to you, check box
at right, complete sections 10 and 11 on the reverse side of this page and DO NOT complete sections 4 and 5 below.
The address(es) of the child(ren) listed in section 2 whose care or custody is at issue in this case is (are)
Child(ren) Address(es) Address(es) During Last 2 Years,
If Different
Child A.
Street Address
Street Address
City, State, Zip Code
City, State, Zip Code
Child B.
Street Address
Street Address
City, State, Zip Code
City, State, Zip Code
Child C.
Street Address
Street Address
City, State, Zip Code
City, State, Zip Code
Section
10
My address is:
Section
11
Street Address, City, State, Zip Code
LIST OF ATTORNEYS AND GUARDIANS AD LITEM / INVESTIGATORS
Please list the names of all attorneys and guardians ad litem involved in the pending proceedings listed in section 7.
1.
Attorney(s) for child(ren) (Please specify if each child is represented by a different attorney.)
2.
GAL(s)/Investigator(s) (Please indicate if a GAL has been appointed to represent a specific child.)
3.
Attorney(s) for mother
4.
Attorney(s) for father
A
D
D
R
E
S
S
E
S
T
O
B
E
K
E
P
T
C
O
N
F
I
D
E
N
T
I
A
L
(Fill Out Below If Applicable)
I, , attorney for D.S.S. or its agent have ascertained from the above checked off attorney(s) and guardian(s) as
litem/investigator(s) a willingness to accept an appointment from the court to represent the same party should the court
elect to make such an appointment.
A
D
D
R
E
S
S
E
S
T
O
B
E
K
E
P
T
C
O
N
F
I
D
E
N
T
I
A
L
(Signature)
AFFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER
OR CUSTODY PROCEEDINGS
Name of
Pursuant to Trial Court Rule IV Case:
Boston District Court Juvenile Court Probate & Family Court Superior Court
Municipal
Court Division Division Division Division
Section
1
I, , hereby declare, to the best of my knowledge, information and belief that all the information
on this form is true and complete:
The name(s) of the child(ren) whose care or custody is at issue is (are):
A. , B. , C. ,
(LAST, FIRST) (LAST, FIRST) (LAST, FIRST)
Section
2
Use only the letter appearing in front of the child’s name above when referring to that child when completing the remaining sections.
Section
3
The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered persons
and their dependent child(ren), or the party filing this affidavit believes that he/she or the child(ren) is/are in danger of physical or
emotional abuse, or the party is filing an action under G.L.c. 209A. If you believe that this provision applies to you, check box
at right, complete sections 10 and 11 on the reverse side of this page and DO NOT complete sections 4 and 5 below.
The address(es) of the above-named child(ren) whose care or custody is at issue in this case is/are:
Address(es) Address(es) During Last 2 Years, If Different
CHILD A.
CHILD B.
CHILD C.
Section
4
My address is:
Section
5
Section
6
I have have not participated in and I know do not know of other care or custody proceedings involving the above-
named child(ren) in Massachusetts or in any other state or country.
Certified copies of any pleadings or determinations in a care or custody proceeding outside of Massachusetts listed in sections 7 and 8 must be filed
with this affidavit unless already filed with this court or an extension for filing these documents has been granted by this court.
The following is a list of all pending or concluded proceedings I have participated in or know of involving the care or custody of the above-
named child(ren):
[W]itness
Letter
of
Child
Court Docket No. Status of Case
(Custody awarded to)
(Date of award)
[P]arty
[O]ther
[N]one
CHILD [ ]
CHILD [ ]
CHILD [ ]
Section
7
The names and addresses of parties to care or custody proceedings involving (any of) the above-named child(ren) or those claiming a
legal right to this (these) child(ren) during the last two years (not including myself) are:
Letter of Child Name of Party/Claimant Current (or last known) Address of Party/Claimant
CHILD
CHILD
CHILD
Section
8
Section
9
If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-
named child(ren) and I am requesting the court to impound this affidavit. See instructions.
This affidavit must be personally signed by the party listed in section 1 above, unless he/she is under 18 years of age or has been adjudged incompetent, in
which case the attorney of record must sign. A revised affidavit must be filed with the court if new information is discovered subsequent to this filing.
Signed this ____________ day of ________________________________, 20 ____, under the penalties of perjury.
X
SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE PRINTED NAME OF PERSON SIGNING
ADDRESS OF ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE
PARTY’S COPY
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.
