On September 13, 2021 a
Party Statement
was filed
involving a dispute between
Clark, Nicole C,
and
for Joint Petition
in the District Court of Barnstable County.
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AFFIDAVIT DISCLOSING CARE | TRIAL COURT OF MASSACHUSETTS pogernmer rR: 9
OR CUSTODY PROCEEDINGS 1p 02 7
Pursuant to Trial Court Rule IV Name of Case Nicole C. Clark and Tyler J. Clark ~
BMC District Court Juvenile Court Prob & Family Court Superior Court
|
Division Division Division Division Division i
Section |, Nicole C. Clark hereby declare, to the best of my knowledge, information, ant
1 belief that all the information on this form is true and complete: !
Section | The name(s) of the child(ren) whose care or custody is at issue in this case are:
2 A. Clark, Myles B. Cc. i
(LAST, FIRST) (LAST, FIRST) (LAST, FIRST) !
Use only the letter appearing In front of the child's name above when referring to that child when completing the remaining sections. !
7
\
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 CO
provision applies to you, check 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(es) During the Last 2 Years, if Different |
CHILD A. Myles L. Clark 25 Chapaquoit Way, East Sandwich, MA 02537 |
CHILD B. |
CHILD C. |
Section :
5 My address is: 65 Highview Drive, Sandwich, Barnstable County, MA 02563
Section | 17 have [J have not participated in and | [1] know XJ do not know of other care or custody proceedings involving the above-named
6 child(ren) in Massachusetts or in any other state or country.
Certified copies of any pleadings or determinations in a care 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 [Plarty
Letter of Child Court Docket No. Status [Other [NJone
CHILD (1
CHILD {1
CHILD 0]
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 this 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 ol
9 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 9th day of September , 2021 under the penalties of perjury.
x : Nicole C. Clark
‘SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT PRINTED NAME OF PERSON SIGNING
"ADDRESS OF ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE \
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.
OCAJ-1 TRC IV (07/95) TurboLaw (800) 518-8726 —(BIR
ono
Document Filed Date
September 13, 2021
Case Filing Date
September 13, 2021
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AFFIDAVIT DISCLOSING CARE | TRIAL COURT OF MASSACHUSETTS pogernmer rR: 9 OR CUSTODY PROCEEDINGS 1p 02 7 Pursuant to Trial Court Rule IV Name of Case Nicole C. Clark and Tyler J. Clark ~ BMC District Court Juvenile Court Prob & Family Court Superior Court | Division Division Division Division Division i Section |, Nicole C. Clark hereby declare, to the best of my knowledge, information, ant 1 belief that all the information on this form is true and complete: ! Section | The name(s) of the child(ren) whose care or custody is at issue in this case are: 2 A. Clark, Myles B. Cc. i (LAST, FIRST) (LAST, FIRST) (LAST, FIRST) ! Use only the letter appearing In front of the child's name above when referring to that child when completing the remaining sections. ! 7 \ 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 CO provision applies to you, check 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(es) During the Last 2 Years, if Different | CHILD A. Myles L. Clark 25 Chapaquoit Way, East Sandwich, MA 02537 | CHILD B. | CHILD C. | Section : 5 My address is: 65 Highview Drive, Sandwich, Barnstable County, MA 02563 Section | 17 have [J have not participated in and | [1] know XJ do not know of other care or custody proceedings involving the above-named 6 child(ren) in Massachusetts or in any other state or country. Certified copies of any pleadings or determinations in a care 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 [Plarty Letter of Child Court Docket No. Status [Other [NJone CHILD (1 CHILD {1 CHILD 0] 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 this 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 ol 9 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 9th day of September , 2021 under the penalties of perjury. x : Nicole C. Clark ‘SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT PRINTED NAME OF PERSON SIGNING "ADDRESS OF ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE \ THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION. OCAJ-1 TRC IV (07/95) TurboLaw (800) 518-8726 —(BIR ono