Massachusetts Affidavit Disclosing Custody Proceedings Form

In case of spouses wanting to reach an agreement regarding the custody of children after the marriage is dissolved in the State of Massachusetts, the Massachusetts Affidavit Disclosing Custody Proceedings Form has to be completed and submitted.

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AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDINGPursuant to Trial Court Rule IVTRIAL COURT OF MASSACHUSETTSName of Case _______________________DOCKET NUMBERBMC________________DivisionDistrict Court________________DivisionJuvenile Court________________DivisionProb & Family  Court________________DivisionSuperior  Court________________DivisionSection1I, _________________________________________________ hereby declare, to the best of my knowledge,information, and belief that all information on this form is true and complete:Section2The name(s) of the child(ren) whose care or custody is at issue in this case are: A. ________________________ B. ___________________________ C. ____________________________                             (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. Section3The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for batteredpersons and their dependent child(ren, or the party filing this affidavit believes that he/she or the child(ren) are in dangerof physical or emotional abuse, or the party is filing an action under G.L. c. 209A.  If you believe that this provisionapplies to you, check the box at right, complete sections 10 and 11 on the reverse side of this page and DO NOTcomplete sections 4 and 5 below. Section4The address(es) of the above-name child(ren) whose care and custody is at issues in this case is/are: Address(es)                                                                        Address\CHILD   A ____________________________________   ______________________________________________________CHILD   B ____________________________________   ______________________________________________________CHILD   C ____________________________________   ______________________________________________________Section5My address is: _______________________________________________________________________________________Section6I 9 have 9 have not participated in and I 9 know  9 do not know of other care or custody proceedings involving the above-nameschild(ren) in Massachusetts or in any 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 mustbe filed with this affidavit unless already filed with this court or an extension for filing these documents has been granted by this court. Section7The following is a list of all pending or concluded proceedings I have participated in or know if involving the care or custody ofthe above named child(dren):                                                                                                                      [W]itness [P]arty   Letter of Child                       Court                                      Docket no.                         Status                 [O]ther     [N]one            CHILD _____             __________________________     _____________    _____________________________ [    ]CHILD _____             __________________________     _____________    _____________________________ [    ]CHILD _____             __________________________     _____________    _____________________________ [    ]Section8The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or thiseclaiming 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/ClaimantCHILD _____   _______________________________________    _____________________________________________CHILD _____   _______________________________________    _____________________________________________CHILD _____   _______________________________________    _____________________________________________Section9If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-named child(ren) and I 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 adjudgedincompetent in which case the attorney of record must sign.  A revised affidavit must be filed with the court if new information is discoveredsubsequent to this filing.  Signed this __________________________ day of ______________________________, 20_______ under the penalties of perjury.X ___________________________________________________                  _____________________________________           SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT                                                         PRINTED NAME OF PERSON SIGNING_____________________________________________________________________________________________________________________________________________________________________ADDRESS OF ATTORNEY OR RECORD FOR JUVENILE/INCOMPETENTTHE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.OCAJ-1 TCR IV (07/95)

READ BEFORE COMPLETING AFFIDAVITA.  WHAT IS AN “AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDING”?  It is a document signed under the penalties of perjury which lists information required by Trial Court Rule IV concerning children involvedin 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 thisaffidavit.   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 theattorney or 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 firstpleading.   This affidavit should be filed upon issuance of a CHINS petition pursuant to G.L. c. 119, not upon application for such a petition.    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 actionis 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 filingof ths affidavit. F.  WHAT MUST BE FILED AS PART OF THIS AFFIDAVIT?   Certified copies of each pleading and of any determination entered in a foreign county or in a state other than Massachusetts must be filedwith 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 thesedocuments. 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 referring.  You must also sign and date the sheet.   The party filing this affidavit must complete the section entitles “Name of Case” and indicate the Court Department and Division in which thecase is being brought.  The docket number should be also be listed, if known.   DO NOT COMPLETE SECTIONS 2, 3, 4, 8 AND 10 IF THIS IS AFFIDAVIT IS BRING FILED WITH A PETITION FOR ADOPTION. Section 1You must print your first and last name.  If this affidavit is filed by an attorney on behalf of an incompetent person or ajuvenile, the name of the party on which behalf this affidavit is being completed must be listed. Section 2List the names of all child(ren) involved in this care or custody proceeding.  All future references to the child(ren) listed inthis 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 referencesto John Smith will be as Child A).Section 3Check the box if this section applies to you.  If this box is checked, do not complete Sections 4 and 5.  You must completeSections 10 and 11 on the reverse side of page 1. Sections 4 & 5List 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 legalcustody. Section 6Check the appropriate box. Section 7List all pending or concluded proceedings which you have participated in or know of involving the care or custody of thechild(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 theproceeding by listing “W” for witness, “P” for party, “O” for other or “N” for none.  If specific information required in thissection 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, thedate of the award and the nature of your participation.  Under the heading “Status of Case”, indicate type of case.Section 8List the name(s) and current residential address(es), if known, otherwise the last known address(es) of parties to care orcustody proceedings or persons claiming a legal right to the above named child(ren) during the last two years.  Do notinclude yourself.  Section 9Check 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 theappropriate motion to be filed. Section COMPLETE ONLY IF YOU CHECKED THE BOX IN SECTION 3. 10 & 11List the present and all prior addresses during the last two years of the child(ren) listed in Section 2 of this affidavit and yourpresent address.  If legal custody of a child has been awarded to a social service agency, list the name and address of theagency with legal custody. Section 12List the attorneys and guardians ad litem/investigators previously appointed in Section 7. SignatureThe party listed in Section 1 must date and sign this affidavit except for an incompetent or juvenile, in which case the attorney ofrecord on behalf of the juvenile or incompetent party must date and sign this affidavit and print his/her name and address. THS AFFIDAVIT MUSTBE FILED WITH THE COURT AND A COPY FURNISHED BY THE PARTY FILING IT TO ALL OTHER PARTIES TO THE ACTION.