On June 10, 2021 a
Party Statement
was filed
involving a dispute between
Camacho Pereira, Maria Daluz,
Pereira, Luis H,
and
for Guardianship Managed
in the District Court of Bristol County.
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Gommonwealth of Massachusetts
The Trial Court
Probate and Family Court Department s .
+S
casename: Giovanna, burs “veces
Public Assistance Affidavit
14 Lowe € se C8 Prone pettionenpalntt, hereby declare that | have made inquiry
and, to the best of my knowledge, information and belief all of the information on this form is true, accurate and complete.
2. The name(s) and address(es) of the child(ren) who is/are the subject of this complaint ar petition:
Name (3) Address.
Gavenn. Lure Pereice, 151 Burts} Tovwoton, Me, d2790
3a. 1am receiving public assistance, Ga. Yes ya No
b. | have received public assistance In the past, QO Yes a ‘No
If the response is yes to either 3a or 3b, please specify the type of public assistance received:
(2 Department of Transitional Assistance (Public Welfare)
1 Department of Social Services
Department of Medical Assistance (Medicaid)
Q Other (Please Specify)
_ 4a. The child(ren) fisted is/are receiving public assistance. a Yes O No
b. The child(ren) fisted has/have received public assistance in the pasL Gives Q No
(f the response is yes to either 4a or 4b, please specify the type of public assistance received:
yf Department of Transitional Assistance (Public Welfare)
Q Department of Social Services
Q Department of Medical Assistance (Medicald)
Other (Please Specify)
This affidavit must be personnally signed by the petitiorier/plaintiff fisted in Section 1. If the petitioner/plaintiff is under
the age of 18 years and is represented by an attorney, the altorney must also sign this affi idavit. A revised affidavit must
be filed with the Court if new information is discoverad subsequent to this filing.
Signed this Hd ae of SUNS 20 zl
signature KOM Printed Name: Lae # ears
Attomey: Printed Name: Me reech due eorreah
og.
6
“i
Document Filed Date
June 10, 2021
Case Filing Date
June 10, 2021
Category
Guardianship Managed
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Gommonwealth of Massachusetts The Trial Court Probate and Family Court Department s . +S casename: Giovanna, burs “veces Public Assistance Affidavit 14 Lowe € se C8 Prone pettionenpalntt, hereby declare that | have made inquiry and, to the best of my knowledge, information and belief all of the information on this form is true, accurate and complete. 2. The name(s) and address(es) of the child(ren) who is/are the subject of this complaint ar petition: Name (3) Address. Gavenn. Lure Pereice, 151 Burts} Tovwoton, Me, d2790 3a. 1am receiving public assistance, Ga. Yes ya No b. | have received public assistance In the past, QO Yes a ‘No If the response is yes to either 3a or 3b, please specify the type of public assistance received: (2 Department of Transitional Assistance (Public Welfare) 1 Department of Social Services Department of Medical Assistance (Medicaid) Q Other (Please Specify) _ 4a. The child(ren) fisted is/are receiving public assistance. a Yes O No b. The child(ren) fisted has/have received public assistance in the pasL Gives Q No (f the response is yes to either 4a or 4b, please specify the type of public assistance received: yf Department of Transitional Assistance (Public Welfare) Q Department of Social Services Q Department of Medical Assistance (Medicald) Other (Please Specify) This affidavit must be personnally signed by the petitiorier/plaintiff fisted in Section 1. If the petitioner/plaintiff is under the age of 18 years and is represented by an attorney, the altorney must also sign this affi idavit. A revised affidavit must be filed with the Court if new information is discoverad subsequent to this filing. Signed this Hd ae of SUNS 20 zl signature KOM Printed Name: Lae # ears Attomey: Printed Name: Me reech due eorreah og. 6 “i