Party Statement: BA21D0593JP DePrieto, Zulma Acosta and Prieto Medina, Edwin

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                                AFFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER
OR CUSTODY PROCEEDING

 

 

 

 

 

 

 

 

Pursuant to Trial Court Rule IV Name of case A Costa De. exieto ad POF
BMC District Court Juvenile Court Prob & Family Court Superior Court
Division Division Division Division Division

Section ||, , hereby declare, to the best of my knowledge, information, and

1 belief that all 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:

; A Acosta, Marly a B. Cc.

(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 | 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 O
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(es) During the Last 2 Years, if Different
cHLDA/Yo MetchellS yoy Hyannis
CHILD B J

CHILD C

 

 

 

Section
5 My address is:

 

 

Section |! Ohave have not participated in and | Oknow Go 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 [P]arty
Letter of Child Court Docket No. Status [O]ther [NJone

CHILD [1

CHILD {]

CHILD t]

 

 

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 | am 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.

Signed this 2} day of scptem ber 20,2) under the penalties of perjury.

Zula £. Awsta Oe puerto

PRINTED NAME OF PERSON SIGNING

 
   

OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT

 

"ADDRESS OF ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.

 

OCAJ-1 TRC IV (07/95)