Party Statement: Archer, Stephanie M vs. Fusco, Glen E

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                                DOCKET NUMBER

ARWIAGY

AFFIDAVIT DISCLOSING CARE ‘TRIAL COURT OF MASSACHUSETTS Lo
OR CUSTODY PROCEEDING

Pursuant to Trial Court Rule tV Name of Case

BMC District Court Juvenile Court Prob & Family Court Superior Court
Berkshire
Division Division’ Division + “Division Division

Section
1

1, Steehanis Betww hereby declare, to the best of my knowledge, information, and
belief that all information on this form is true and complete:

The name(s) of the child(ren) whose care or custody is at issue in this case are:

A. Fusco E\ eX —_ : c
(LAST, FIRST) (LAST, FIRST) (LAST, FIRST)

Use only the letter appearing in front of the child's name above when referring to the child in completing the remaining sections.

Section
2

Section ] The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered
3 persons and their dependent child(ren), or the party filing this affidavit believes that he/she or the child(ren) 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 CI

provision applies to you, check the box at right, complete sections 10 and 11 on the reverse side of this page

and DO NOT complete sections 4 and 5 below.

Section | The address(es) of the above-named child(ren) whose care and custody is at issue in this case is/are:

4 Address(es): Address .
CHILDA Ely Gag co tos! Apt 2 Mainsk Wousatonic (MA Ware
CHILD B
CHLDC

Section

Apt
5 My address is: {05° $ Mas st House tonite MA CiAZR&

| Z have Ohave not participated in and | know Dido not know of other care or custody proceedings invotving the above-named
child(ren) in Massachusetts or in any state or country. ~

Section
6

Certified copies of any pleadings or determinations in care a or custody proceeding outside of Massachusetts listed in Sections 7 and &
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.

Section

The following is a list of all pending or concluded proceedings ! have participated in or know of involving the care or custody of
7

the above-named child(ren): {Witness [Plarty

Letter of Child _ Court Docket No. Status [O}ther [NJone
CHILD J Berk un 17S Dismisse t '
CHILD tl

Section
8

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 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
cH Glen Fusco RAYA MeainkSt Recket ma aar
CHILD
CHILD ,

If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-named
child(ren) and | 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 A day of 3 o 20 Qa under the penalties of perjury.
x Stephanie Arche
OF PARTY OR ATTORNEY OF RECORD FOR JUVENILEANCOMPETENT ~~ PRINTED NAME OF PERSON SIGNING

“ADDRESS OF ATTORNEY OF RECORD FOR JUVENILE/NCOMPETENT
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS At

OCAJ-4 TRC IV (07/95)ee -4ezmMmo-nzZz00 40M MD OA aMmaamaIIy

‘ The party filing this affidavit may request certain address(es) to be kept confidential if the address is a shelter for battered persons
p | and their dependent child(ren), or the party filing this affidavit believes that he/she or the child(ren) are in danger of physical or
R | emotional abuse, or the party is filing an action under G.L. c. 209A. If you checked the box in section 3 indicating that you
believe the above provision applies to you, complete sections 10 and 11 below, and DO NOT complete sections 4 and 5.
s
E The address(es) of the child(ren) listed in section 2 whose care or custody is at issue in this'‘case
s are:
3 i Child(ren) Address(es) Address(es) During Last 2 Years,

1 : If Different
Child A.

Street Address Street Address
K
E
p | Section Gi, Stale, Zip Code City, State, Zip Code
T 10 | Child B.
Cc “Street Address ‘Street Address
oO
City, State, Zip Code City, Stale, Zip Code
| Child C.
. Street Address Street Address _
E i
. City, State, Zip Code City, Stale, Zip Code
' .
A i .
L Secon My address is:
‘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.

i 1 ‘Attomey(s) for child(ren), (Please specify f each child is represented by a different atlorney.)

! Go

i 2,

i GAL(s)Minvestigator(s) (Please indicate ifs GALhas been appointed fo represent a specific child.)

Pog

Section i 30
12 . “Atforney(s) far mother

i Q

14d

i AUtorRey(S) Tor Fane

| (Fill Out Below !f Applicable)

L, - , attorney for
D.C.F. or its agent have ascertained from the above checked off attorney(s) and guardian(s) ad
litem/investigators a willingness to accept an appointment from the court to represent the same
party should the court elect to make such appointment.

(Cignature)