Affidavit Disclosing Care or Custody Proceeding

Requesting the disclosure of proceedings related to care or custody requires the execution of the following affidavit.

Extracted Text for Proper Search

OCAJ-1 TRC IV (07/95)
AFFIDAVIT DISCLOSING CARE
OR CUSTODY PROCEEDING
Pursuant to Trial Court Rule IV	TRIAL COURT OF MASSACHUSETTS
 
Name of Case	
DOCKET NUMBER	
BMC
Division	District Court
Division	Juvenile Court
Division	Prob & Family Court
Division	Superior Court
Division	
Section1	I,                                                                      \�                                 hereby declare, to the best of my knowl\�edge, information, and
belief that all information on this form is true and complete:	
(LAST, FIRST)	(LAST, FIRST)	(LAST, FIRST)	
Section2	The name(s) of the child(ren) whose care or custody is at issue in t\�his case are:
 A.                                                           B.        \�                                                    C.
Use only the letter appearing in front of the child's name above when re\�ferring to the child in completing the remaining sections.	
Section3	The  party  filing this affidavit  may request  certain addresses  to be  kept  confidential  if the  address  is a shelter  for battered
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
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 4	The address(es) of the above-named child(ren) whose care and custody\� is at issue in this case is/are:
Address(es):            Address
CHILD A
CHILD B
CHILD C	
Section 5	
My address is:	
Section6	I     have    have not participated in and I     know     do not know of\� other care or custody proceedings involving the above-named
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 o\�r an extension for filing these documents has been granted by this court\�.
Section7	The following is a list of all pending or concluded proceedings I have p\�articipated in or know of involving the care or custody of
the above-named child(ren):                                           \�                                                                        \�          [W]itness [P]arty
   Letter of Child            Court                                     \�    Docket No.                         Status                           \�   [O]ther     [N]one
CHILD                [   ]
CHILD              [   ]
CHILD              [   ]	
Section
8	The names and addresses of parties to care or custody proceedings involv\�ing any of the above-named child(ren) or those
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	
Section9	If the box at the right is checked, this affidavit discloses the adoptio\�n of one or more of the above-named
child(ren) and I am requesting the court to impound this affidavit.  S\�ee 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 a\�ffidavit must be filed with the court if new information is discovered
subsequent to this filing.
 Signed this                                                       day o\�f                                                           , 20        \�         under the penalties of perjury.
 X
 
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER P\�ARTIES TO THIS ACTION.	
SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT	PRINTED NAME OF PERSON SIGNING	
ADDRESS OF ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT	
___________________________________________________

The party  filing this affidavit  may request  certain address(es)  to be  kept  confidential  if the  address  is a shelter  for battered  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  checked  the box  in section  3 indicating  that you
believe the above provision applies to you, complete sections 10 and 11 \�below, and DO NOT complete sections 4 and 5.
Section 10	
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The address(es) of the child(ren) listed in section 2 whose care or \�custody is at issue in this case
are:
Child(ren)    Address(es) Address(es) During Last 2 Years,
                    If Different
Child A.
Child B.
Child C.	
Street Address
City, State, Zip Code	
Street Address
City, State, Zip Code	
Street Address
City, State, Zip Code	
Street Address
City, State, Zip Code	
Street Address
City, State, Zip Code	
Street Address
City, State, Zip Code	
Section 11	My address is:	Street Address, City, State, Zip Code	
Section12	
LIST OF ATTORNEYS AND GUARDIANS AD LITEM/INVESTIGATORS
Please list the names of all attorneys and guardians ad litem involved i\�n the pending
proceedings listed in section 7.
1.
2.
3.
4.	
Attorney(s) for child(ren).  (Please specify if each child is repre\�sented by a different attorney.)
GAL(s)/Investigator(s) (Please indicate if a GALhas been appointed \�to represent a specific child.)
Attorney(s) for mother
Attorney(s) for father	
(Fill Out Below If Applicable)
      I,                                                                                                                              ,  attorney  for
D.C.F.  or its  agent  have ascertained  from the above  checked  off attorney(s)  and guardian(s)  ad
litem/investigators  a willingness  to accept  an appointment  from the court  to represent  the same
party should the court elect to make such appointment.	
(Signature)

READ BEFORE COMPLETING THE AFFIDAVIT
A.  WHAT IS AN "AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDING"?	
   It is a document signed under the penalties of perjury which lists infor\�mation required by Trial Court Rule IV concerning children involved
in a care or custody proceeding.
B.  WHO MUST FILE THIS AFFIDAVIT?
   The  party  to a petition  (including  a modification  petition) or complaint  involving the care,  custody,  visitation,  or change  of name  of a child
pursuant  to G.L.  c. 119  (except  delinquency  actions under G.L. c. 201,  G.L. c. 207,  G.L. c. 208,  G.L. c. 209,  G.L. c. 209A,  G.L. c. 209C,  G.L.
c. 210, or any other provision of law concerning the care or custody of \�a child must file this affidavit.
    This  affidavit  must be signed  by the  party  unless  the party  is under  18 years  of age  or has  been  adjudged  incompetent  in which  case the
attorney of record must sign this affidavit on behalf of the juvenile or\� incompetent party.
C.  WHEN MUST THIS AFFIDAVIT BE FILED?
    The  person  filing the petition  or complaint  must file this  affidavit  at the  time  of filing  and the other  party must file this  affidavit  with the first
pleading.
    This affidavit should be submitted upon the filing of  an applicatio\�n for a Child Requiring Assistance (CRA) pursuant to G.L. c. 119.
    This affidavit need not be filed if the petition or complaint is for\�  support only.
 D.  WHERE MUST THIS AFFIDAVIT BE FILED?
    The  completed  affidavit must be filed,  in person  or by  mail,  with the Clerk-Magistrate  or Register  of Probate  in the  court  in which  this action
is being brought.
E.  WHEN MUST A REVISED AFFIDAVIT BE FILED?
     A  revised  affidavit  must be filed  with the Clerk-Magistrate  or Register  of Probate  if new  information  is discovered  subsequent  to the  filing  of
this affidavit.
F.  WHAT MUST BE FILED AS PART OF THIS AFFIDAVIT?
    Certified  copies of each  pleading  and of any  determination  entered in a foreign  country  or in a state  other  than Massachusetts  must be
filed  with this affidavit  unless these documents  are on file  with  the court  in this  case,  or an  extension  has been  granted  by the  court  for filing
these documents.
INSTRUCTIONS FOR COMPLETING AFFIDAVIT
    When  completing  this affidavit  if additional  space is needed  for any  of the  sections,  attach a separate  sheet which  includes  your name
(printed), the docket number and the sections to which you are referri\�ng.  You must also sign and date the sheet.
    The  party  filing this affidavit  must complete  the section  entitled  "Name of Case"  and indicate  the Court  Department  and Division  in which
the case is being brought.  The docket number should also be listed, if \�known.
DO NOT COMPLETE SECTIONS 2, 3, 4, 8 AND 10 IF THIS AFFIDAVIT IS BEING FI\�LED WITH A PETITION FOR ADOPTION.
Section 1
Section 2
Section 3
Sections 4 & 5
Section 6
Section 7
Section 8
Section 9
Sections 10 & 11
Section 12
Signature	You  must  print your first and  last name.   If  this  affidavit  is filed  by an  attorney  on behalf  of an  incompetent  person or a
juvenile, the name of the party on which behalf this affidavit is being \�completed must be listed.
List  the names  of all  child(ren)  involved in this  care  or custody  proceeding.   All  future  references  to the  child(ren)  listed in
this  section  should be with  the letter  in front  of the  child's  name (e.g. If John  Smith  is listed  next to the  letter  A, all
references to John Smith will be as Child A).
Check  the box  if this  section  applies to you.   If  this  box  is checked,  do not  complete  Sections 4 and  5.  You  must  complete
Sections 10 and 11 on the reverse side of page 1.
List  the present  and all prior  addresses  during the last  two years  of the  above-named  child(ren) and your  present  address.
If  legal  custody  of a child  has been  awarded  to a social  service  agency,  list the  name  and address  of the  agency  with legal
custody.
Check the appropriate box.
List  all pending  or concluded  proceedings  which you have  participated  in or  know  of involving  the care  or custody  of the
child(ren)  named in this  affidavit.   Indicate  the letter  of the  child;  the court  in which  the case  was heard,  the docket  number,
the  person(s)  to whom  custody  was awarded,  and the date  of the  award,  and the nature  of your  participation  in the
proceeding  by listing  "W" for witness,  "P" for party,  "O" for other  or "N"  for none.   If  specific  information  required in this
section  is not  known,  you or your  attorney  should contact  the court  where  the case  was heard  to obtain  such information  .
In  the  case  of a petition  for adoption,  list all information  except the person(s)  to whom  custody  was awarded,  the
date of the award and the nature of your participation.  Under the headi\�ng "Status of Case", indicate type of case.
List  the name(s)  and current  residential  address(es),  if known,  otherwise  the last  known  address(es)  of parties  to care  or
custody  proceedings  or persons  claiming  a legal  right to the  above-named  child(ren) during the last  two  years.   Do  not
include yourself.
Check  this box  if this  affidavit  discloses  the adoption  of a child  and you are requesting  the court  to impound  this affidavit.   If
this  provision  is applicable,  you should  contact  the Clerk-Magistrate  or Register  of Probate  for assistance  concerning  the
appropriate motion to be filed.
COMPLETE ONLY IF YOU CHECKED THE BOX IN SECTION 3.
List  the present  and all prior  addresses  during the last  two years  of the  child(ren)  listed in Section  2 of  this  affidavit  and
your  present  address.   If  legal  custody  of a child  has been  awarded  to  a  social  service  agency,  list the  name  and address
of the agency with legal custody.
List the attorneys and guardians ad litem/investigators previously appoi\�nted in Section 7.
The  party  listed  in Section  1 must  date and sign  this affidavit  except for an incompetent  or juvenile,  in which  case the
attorney  of record  on behalf  of the  juvenile  or incompetent  party must date and sign  this affidavit  and print  his/her  name
and address.	
THIS AFFIDAVIT MUST BE FILED WITH THE COURT AND A COPY FURNISHED BY THE \�PARTY FILING IT TO ALL OTHER PARTIES TO THIS ACTION.