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AFFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER
Paranal to ied Got eae Name of Case : 22. pb \ 5 G s
BMC District Court duvenile Court | Prob & Family Court Superior Court
Division Division Division Division Division ~
Section | |, Shacvene PLNSAO . hereby declare, to the best of my knowledge,
1 information, and belief that all information on this form fs frue and camplete:
Section | The name(s) of the child(ren) whose ca care or custody Is at issue in this case are:
Beis mawuwsneion \ecoe _e oe DeNoie micnae\
Use anty the ter appocring in font of the chid’s name SSoeah when refering fo the child in comping te remahing sections.
Section The party Sng this affidavit may request cerlait addresses to be Kept cnfdenfal W the adres i ashe for battered
3 Persons and their depenclent chad(ren, ar the party filing this affidavit beléves that he/she or the chifd(ren) are in dangér Ol
of physical or emotional abuse, or the parly Is fling an action under GL c. 2098. Hf you believe that this prot vision
applies to you, choek the box alright, complete sectfone 40 and 11 of the reverse ste ofthis page and DO NOT
Complete sections 4 and § below.
Section iene off above nama eile) wise car an Geta a ass i ce ar .
S| sy ssucsis DUA BAKO Que thaw ma oul )
Section | ahave Bhave not parficfpated in and Lo know natn or orc oni romain shores
_& CHE (en) fh Massachussetts or any state or coutry. .
of any pleadings of deletions na lars o; eu procoadng aula of Naicachusals bandh cadionay and cash
affidavit tniess-already fled this colt or an extension for filing these docuinents has been granted by this court
Section The following s a Bet of al penting or conctuded proceedings | have parfiinted in or know iwthng the care or custody of
7 the above named chid(dren): Diness [Pjarly
Letter of Child Court Docket na. Status {Ofher [NJone
CHILD Py \ 20 CEDAR VY. []
CHILD “3 = ee _ = [1
CHLD C_ __f ]
Section The names and ackiresses of parties to care oc custody proceedings involving any af the above-named chli(ren) or thise
8 chiming a legal right to these child(ren) during the last two years (not including myself) arec
Letter of Child Nats of PariylGitant : Curent (ost nt) Adesso Partyiainart
Section | If tlie box at the rights oheskéd, this affidavit discloses the” "adoption of one or more of the above- Oo
9 named child(ren) and Jam requesting the court to impound this affidavit. See instructions,
This affidavit must be personaly signed by the party Usted in section 4 above, unless he/she is under 18 years of aje or has been adjudged
incompetent in which case the attomey of record must sign. Arrevised affidavit must be fled with the court ifnew information is disoovered
subsequent to this fling,
signed his PHOO, : day of Ws 20. LON ander the penales of posury.
x Lhagies PON p Chee Renate
2 Baan’ Ae 10 ORLA NY Ie ANB Geli)
THE PART? FILING THIS AFFIDAVIT ust FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.
OCAS-1 TCR IY (07795) .READ BEFORE COMPLETING AFFIDAVIT
A. WHAT &S AN “AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDING"?
[tis a dacurnent signed under the penalties of perjury which lists information required by Trial Court Rule IV conceming children Involved
in a care or Custody proceeding.
8. WHO MUIST FILE THIS AFFIDAVIT?.
“The party te> a pefition (Including a modification petitien) or complaint involving the care,
custady, visitzation, or change of name of a child pursuant tp G.L. ¢. 119 (except delinquency actions under G.L, c. 201, G.L. ¢ 207,61.
208, GL. ¢. 209, GL c. 209, G1. 209C, GL c. 210, or any cther provision af law concerning the care or custody of a child must fle this
affidavit. : .
“This affidavit must be signed by the party unless the party is under 18 years of age orhas been adjudged incompetent in which case the
attomey or rescord must sign this affidavit on behaif of the juvenile or incompetent party.
©. WHEN MUSST THIS AFFIDAVIT BE FILED? - Loe
The pérson ‘fling the pefition or complaint must fife this affidavit at the time af filing and the other party must fle this affidavit with the first
Pleading. oe
This affidavit should be filed, upon issusince of a CHINS petition pursuant tp G.L c. 119, not upon application for such a petition.
This affidavit need nat be fled # the petition or complaintis fersuppartonly. _ .
D. WHERE RAUST THIS AFFIDAVIT BE FILED? _ .
aid efent ust ed, n pertom orb ha wih Se Cer Magirate or Register of Probate in the court in which this action
MUST A REVISED AFFIDAVIT BE FILED? . . . :
vit must be fléd With the Cle‘k-Magistrate or Reglster of Prabata if new information fs discovered subsequent fo the fling
F, WHAT MUST BE FILED AS PART OF THIS AFFIDAVIT? . . ea
Ceriified copies of each pleading and of any determination entefed in a foreign county crin a state other than Massachusetts must be fled
with affidavit unless these documents are on fle with the courtin tis case, or an extension has been granted by the court far fling these
a :
INSTRUCTIONS FOR COMPLETING AFFIDAVIT . .
‘When completing this affidavit if additional space Is needed for any of the sections, altach a separate sheet which includes your name
(printed), tha docket number and the sections fo which you are referring. ‘You must aisa sign and date the sheet
The party fling fis afidavit must complete the section entitles “Namo of Case" and indicats tha Court Department and Division in which the
case is being brought, The docket number should be alsa be Usted, if known. vo . .
DO NOT COMPLETE SECTIONS 2, 3, 4, § AND 10 IF THIS [S AFFIDAVIT IS BRING | WITH A PETITION FOR ADOPTION.
Section 1 You must print your first aqd fast naire. if this affidavit 's filed by an attamey on behalf of an incampetant person ora
Juvenile, tha name of the party on which behalf this affidavit is being completed must be listed.
Section 2 st the names of all chikl(ren) invalved in this care of custody proceeding. All future references to the child(reti) fisted in
Toe thés section should be with the latter in front of the child's name (2.9. i John Smith is Bsted naxtto the leiter A, allreferences
. to Jehn Smith will be as Chad A), . “ oo, :
Section3 Check the bax if this ‘section applies to you. if this box is checkad, do not complete Sections 4,and 5. You must camplete
Sections 10 and 11 on the reverse side of page 1. . ‘ :
f the above-named child(ren) and your present address.
Sections4& 5 List the presentand all prior addresses during the last two years o
iflegat cusindy of a chid has been awanied to a social sarvice agency, ist the name and address af the agency with legal
Section § Check the appropriate bixx. . . . . | a
Section 7 Ust all pending ar concluded proceedinga which you have pariicipated in or know af involving the care or custody af the
child(ren) named in this affidavit. indicate the letler of the child; the court in which the.case was heard, the docket number,
section is nat known, you or your attomey shuld contact the court where the case was heard to
In the case of a petition for adoption, list all information except the person(s) t fc
. date of the award and the nature of your participation. Under the heading “Status of Case”, indicate type of case.
Section 3 List the natne(s) ard current residential address(es), known, otherwise the last known address(es) cf partes to care or
custody proceedings of persons claiming a legal right to.the above named child(ren) duririg thé lasf two years. Do not
include yourself, So ge
Section 9 Check this box if this affidavit discloses the adoption of a child and you are requesting. the court to impound this affidavit.
ifthis provision is applicable, you should cantact the Clerk-Magistrate or Register of Probate {pr assistance conceming the
appropriate maticn to ke fled. " 4
Section COMPLETE ONLY IF YOU CHECKED THE BOX IN SECTION 3.
Seciion 2 of this affidavit and your
List the present and all prior addresses during the tast two ysars of the child(ren) sted in
present address. If legal custody of a child has been awarded toa social service agency,
agency with fegal custody.
Section 12 List the atfomeys and guardians ad fitenvinvestigaters previously appointed In Section 7.
‘SignatureThe party sted in Section 1 must date and sign this affidavit except for an incompetent or juvenile, in which case the attomey of
record on behalf ofthe juvenile or incompetent party must date and sign this affidavitand print his/her name and address. THS AFFIDAVIT BUST
BE FILED WITH THE GOURT AND A COPY FURNISHED BY THE PARTY FILING IT To ALL OTHER PARTIES TO THE ACTION.
10811
Bstthe name and address of the
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All 8-1-2 AFFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER Paranal to ied Got eae Name of Case : 22. pb \ 5 G s BMC District Court duvenile Court | Prob & Family Court Superior Court Division Division Division Division Division ~ Section | |, Shacvene PLNSAO . hereby declare, to the best of my knowledge, 1 information, and belief that all information on this form fs frue and camplete: Section | The name(s) of the child(ren) whose ca care or custody Is at issue in this case are: Beis mawuwsneion \ecoe _e oe DeNoie micnae\ Use anty the ter appocring in font of the chid’s name SSoeah when refering fo the child in comping te remahing sections. Section The party Sng this affidavit may request cerlait addresses to be Kept cnfdenfal W the adres i ashe for battered 3 Persons and their depenclent chad(ren, ar the party filing this affidavit beléves that he/she or the chifd(ren) are in dangér Ol of physical or emotional abuse, or the parly Is fling an action under GL c. 2098. Hf you believe that this prot vision applies to you, choek the box alright, complete sectfone 40 and 11 of the reverse ste ofthis page and DO NOT Complete sections 4 and § below. Section iene off above nama eile) wise car an Geta a ass i ce ar . S| sy ssucsis DUA BAKO Que thaw ma oul ) Section | ahave Bhave not parficfpated in and Lo know natn or orc oni romain shores _& CHE (en) fh Massachussetts or any state or coutry. . of any pleadings of deletions na lars o; eu procoadng aula of Naicachusals bandh cadionay and cash affidavit tniess-already fled this colt or an extension for filing these docuinents has been granted by this court Section The following s a Bet of al penting or conctuded proceedings | have parfiinted in or know iwthng the care or custody of 7 the above named chid(dren): Diness [Pjarly Letter of Child Court Docket na. Status {Ofher [NJone CHILD Py \ 20 CEDAR VY. [] CHILD “3 = ee _ = [1 CHLD C_ __f ] Section The names and ackiresses of parties to care oc custody proceedings involving any af the above-named chli(ren) or thise 8 chiming a legal right to these child(ren) during the last two years (not including myself) arec Letter of Child Nats of PariylGitant : Curent (ost nt) Adesso Partyiainart Section | If tlie box at the rights oheskéd, this affidavit discloses the” "adoption of one or more of the above- Oo 9 named child(ren) and Jam requesting the court to impound this affidavit. See instructions, This affidavit must be personaly signed by the party Usted in section 4 above, unless he/she is under 18 years of aje or has been adjudged incompetent in which case the attomey of record must sign. Arrevised affidavit must be fled with the court ifnew information is disoovered subsequent to this fling, signed his PHOO, : day of Ws 20. LON ander the penales of posury. x Lhagies PON p Chee Renate 2 Baan’ Ae 10 ORLA NY Ie ANB Geli) THE PART? FILING THIS AFFIDAVIT ust FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION. OCAS-1 TCR IY (07795) .READ BEFORE COMPLETING AFFIDAVIT A. WHAT &S AN “AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDING"? [tis a dacurnent signed under the penalties of perjury which lists information required by Trial Court Rule IV conceming children Involved in a care or Custody proceeding. 8. WHO MUIST FILE THIS AFFIDAVIT?. “The party te> a pefition (Including a modification petitien) or complaint involving the care, custady, visitzation, or change of name of a child pursuant tp G.L. ¢. 119 (except delinquency actions under G.L, c. 201, G.L. ¢ 207,61. 208, GL. ¢. 209, GL c. 209, G1. 209C, GL c. 210, or any cther provision af law concerning the care or custody of a child must fle this affidavit. : . “This affidavit must be signed by the party unless the party is under 18 years of age orhas been adjudged incompetent in which case the attomey or rescord must sign this affidavit on behaif of the juvenile or incompetent party. ©. WHEN MUSST THIS AFFIDAVIT BE FILED? - Loe The pérson ‘fling the pefition or complaint must fife this affidavit at the time af filing and the other party must fle this affidavit with the first Pleading. oe This affidavit should be filed, upon issusince of a CHINS petition pursuant tp G.L c. 119, not upon application for such a petition. This affidavit need nat be fled # the petition or complaintis fersuppartonly. _ . D. WHERE RAUST THIS AFFIDAVIT BE FILED? _ . aid efent ust ed, n pertom orb ha wih Se Cer Magirate or Register of Probate in the court in which this action MUST A REVISED AFFIDAVIT BE FILED? . . . : vit must be fléd With the Cle‘k-Magistrate or Reglster of Prabata if new information fs discovered subsequent fo the fling F, WHAT MUST BE FILED AS PART OF THIS AFFIDAVIT? . . ea Ceriified copies of each pleading and of any determination entefed in a foreign county crin a state other than Massachusetts must be fled with affidavit unless these documents are on fle with the courtin tis case, or an extension has been granted by the court far fling these a : INSTRUCTIONS FOR COMPLETING AFFIDAVIT . . ‘When completing this affidavit if additional space Is needed for any of the sections, altach a separate sheet which includes your name (printed), tha docket number and the sections fo which you are referring. ‘You must aisa sign and date the sheet The party fling fis afidavit must complete the section entitles “Namo of Case" and indicats tha Court Department and Division in which the case is being brought, The docket number should be alsa be Usted, if known. vo . . DO NOT COMPLETE SECTIONS 2, 3, 4, § AND 10 IF THIS [S AFFIDAVIT IS BRING | WITH A PETITION FOR ADOPTION. Section 1 You must print your first aqd fast naire. if this affidavit 's filed by an attamey on behalf of an incampetant person ora Juvenile, tha name of the party on which behalf this affidavit is being completed must be listed. Section 2 st the names of all chikl(ren) invalved in this care of custody proceeding. All future references to the child(reti) fisted in Toe thés section should be with the latter in front of the child's name (2.9. i John Smith is Bsted naxtto the leiter A, allreferences . to Jehn Smith will be as Chad A), . “ oo, : Section3 Check the bax if this ‘section applies to you. if this box is checkad, do not complete Sections 4,and 5. You must camplete Sections 10 and 11 on the reverse side of page 1. . ‘ : f the above-named child(ren) and your present address. Sections4& 5 List the presentand all prior addresses during the last two years o iflegat cusindy of a chid has been awanied to a social sarvice agency, ist the name and address af the agency with legal Section § Check the appropriate bixx. . . . . | a Section 7 Ust all pending ar concluded proceedinga which you have pariicipated in or know af involving the care or custody af the child(ren) named in this affidavit. indicate the letler of the child; the court in which the.case was heard, the docket number, section is nat known, you or your attomey shuld contact the court where the case was heard to In the case of a petition for adoption, list all information except the person(s) t fc . date of the award and the nature of your participation. Under the heading “Status of Case”, indicate type of case. Section 3 List the natne(s) ard current residential address(es), known, otherwise the last known address(es) cf partes to care or custody proceedings of persons claiming a legal right to.the above named child(ren) duririg thé lasf two years. Do not include yourself, So ge Section 9 Check this box if this affidavit discloses the adoption of a child and you are requesting. the court to impound this affidavit. ifthis provision is applicable, you should cantact the Clerk-Magistrate or Register of Probate {pr assistance conceming the appropriate maticn to ke fled. " 4 Section COMPLETE ONLY IF YOU CHECKED THE BOX IN SECTION 3. Seciion 2 of this affidavit and your List the present and all prior addresses during the tast two ysars of the child(ren) sted in present address. If legal custody of a child has been awarded toa social service agency, agency with fegal custody. Section 12 List the atfomeys and guardians ad fitenvinvestigaters previously appointed In Section 7. ‘SignatureThe party sted in Section 1 must date and sign this affidavit except for an incompetent or juvenile, in which case the attomey of record on behalf ofthe juvenile or incompetent party must date and sign this affidavitand print his/her name and address. THS AFFIDAVIT BUST BE FILED WITH THE GOURT AND A COPY FURNISHED BY THE PARTY FILING IT To ALL OTHER PARTIES TO THE ACTION. 10811 Bstthe name and address of the