Party Statement: NO21W0283WD Cannistraro, Timothy John vs. Richter, Elise Jennifer

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                                AFFIDAVIT DISCLOSING GARE TRIAL COURT OF MASSACHUSETTS “| becker NuMBER
|, OR CUSTODY PROCEEDING 2190283

 

 

 

 

 

 

 

 

 

 

 

Pursuant to Trial Court Rule IV Name of Case !

BMC District Court Juvenile Court Prob & Family‘Court Superior Court

Division Division Division Division t Division

Section | 1, {\ ‘ N hereby declare, to the best of my knowledge, information, and

 

4 belief that all infofmation on this rm is true and complete:

 

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

3 :
A_Gewn igtraro B. c.
(AST, FIRST) (AST, FIRST) (AST, 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 | 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. 2094. If you believe that this im
Provision applies to you, check the box at right, complete sections 10 and 114 on the reverse side of this page
and DO NOT.cormplete 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): : ©205>/ddress(es) During the Last 2 Years, if Different
CHIDA_IG Mo.Ple St MEDFIELD, MAO) Mant ot Neednicmn MA 08493.
CHILD B }
CHILD C
Section .
5 [Myaddressiss_1_Golitcamb Garden Plymovtn MA C2360 :
Section {10 havehave Not participated in and i Cknow JXdo not know of other care or custody Proceedings involving the above-named
6 child(ren) in Massachusetts or in any state or country.

 

Certified copies of any pleadings or determinations in care a 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.

 

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 [PJarty
Letter of Child Court Docket No. Status [O]ther [NJone
CHILD Norfolk NOzWoe2WwdD ACH ve C]
CHILD 01
CHILD tl
Section | The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or those
8 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
CHILD
CHILD
CHILD

 

 

Section | If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-named
9 child(ren) and tam requesting the court to impound this affidavit. See instructions. O

 

 

 

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.

Signedthis EF igh th day of du une +20 GL) _ under the penalties of perjury.

oo Mistrare
‘SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR SUVENILEINCOMPETENT PRINTED NAME OF PERSON, ‘SIGNING

‘ADDRESS OF ATTORNEY OF RECORD FOR JUVENILEINGOMPETENT
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.

 

 

 

 

 

 

OCAN-4 TRC IV (07/95) v