Party Statement: ES21D1771DR Vongphachanh, Somvilay vs. Vongphachanh, Noupian

• 
• 
• 
• 

						
                                
Preview
                                FIRED <> 91 97

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ArFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS © 7] POCKET NUMBER
OR CusTopy PROCEEDING 6G \Ditt (SR
Pursuant to Trial Court Rule Iv Name of Case 2
BMC District Court Juvenile Court Prob & Family Court 7 Superior Court
Division Division Division Division Division
Section ||, Mma Vow by hereby declare, to the best of my knowledge, information, and
1 belief that all informatio on this form is and complete:
Section | The Name(s) of the child(ren) whose Care or custody is at issue in this case are:
2 { °
AVon hacha Brianna a. c.
(LAST, FIRST) (LAST, FIRST) (LAST, FIRST)
Use only the letter appearing in front of the child's name above when refering to the child in completing the temaining sections.
Section The party filing this affidavit May request certain addresses to be kept confidential it 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 motional abuse, or the party is filing an action under G.L. c. 209A. If you believe that this oO
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 & 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(es) During the Last 2 Years, if Different
CHILD A Vong phachanh Briayua Bel € Belgravia AVE FRESNO . CA osrh
CHILD B : we
CHILDG
Section . > :
5 My address is: 71g Sow ayn ST. averhi|t MA, o1g3
Section |! have Ohave not Participated in and | Aknow Odo not know Of other care or custody Proceedings involving the above-named
6 child(ren) in Massachusetts or in any state or country,

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

Section The following is a list of ail Pending or concluded Proceedings ! have Participated in or know of involving the care Or custody of
7 the above-named child(ren): ., to Miitness [Plarty
Letter of Child Court Docket No. Status {O}ther [None
CHILD . [)
CHILD 0)
CHILD . [}
Section | the fnames-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 fast known) Address of Party/Claimant
CHILD AL: Novela Vonspha chanh 5Spl € Beleravian Ave FPEENO CA.
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 { am Tequesting the court to impound this affidavit. See instructions, oO

 

 

 

 

This affidavit must be Personally signed by the Party listed in section 7 above, unless he/she is under 18 years of age or has been adjudged
incompetent in Which case the attomey of record must sign. A revised affidavit must be filed with the court if new information is discovered
subsequent to this filing.

oOo _ day of May 120 Lt under the Penalties of perjury.
: g
x

 

 

a Somvilay Vo ah
SIGNATURE OF PARTY OR ATTORNEY OF, RECORD FOR UVENILE/ANCOMPETENT PRIN 1E OF PERSON S| ING.

 

 

 

 

 

 

 

 

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

 

 

OCAs-1 TRE Iv (07/98)PPT A= mo-nz00 4am ma 04 omuamnvoe>

 

 

The address(es) of the child(ren) listed in section 2 whose care or Custody is at issue in this case
are:

Address(es) During Last 2 Years,

 

 

 

 

 

 

 

 

 

Child(ren) Address(es)
If Different
i; ChiidA. 5Sb1 G_ Belaravio_
‘Street Address: Steel Address
FRESNO CA G3 27
Section City, State, Zip Code City, State, Zip Code
10 Child B.
‘Steel Addrass ‘Street Address
i City, State, Zip Code City, State; Zip Code
Child C.
‘Street Address Siteel Address
: City, State, Zip Code City, State, Zip Code
Sector | My address is: 14S. Main st Haverhs)l MA olga
i ‘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.
1.0 N/A
(8) for children) 9@ Spec ‘each child is represented ‘by a diferent atomey.)
Qo
Oo
20
GAL (e)investigator(s) (Please Indicate fa GALhas been appointed to Fepresent a specific child.)
g :
oO
Section 3.0 NIA
12 - Attomey(s) for mother
Oo
4.0

 

 

 

 

 

 

 

 

 

 

 

WINE

‘Altomey(S) tor lather

(Fill Out Below If Applicable)

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

party should the court elect to make such appointment,
‘Gignatife) d - —_———— |

 

 

CP-szmMo~1z200 4°UmMk ma On umaum~uUUD