ADDRESSES TO BE KEPT CONFIDENTIAL - A D D R E S S E S 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. The address(es) of the child(ren) listed in section 2 whose care or custody is at issue in this case are: T 0 B E K E p T Child(ren) Section 10 Address(es) Address(es) During Last 2 Years, If Different Child A. City, State, Zip Code City, State, Zip Code City, State, Zip Code C O N F I D E N T I A L City, State, Zip Code Child C. Street Address Street Address City, State, Zip Code City, State, Zip Code My address is: 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. Section 12 Attorney(s) for child(ren). (Please specify if each child is represented by a different attorney.) 2. GAL(s) Investigator(s) (Please indicate if a GAL has been appointed to represent a specific child.) 3. 4. Attorney(s) for mother Attorney(s) for father B E Street Address Child B. Section 11 T 0 K E p T Street Address Street Address C O N F I D E N T I A L Street Address A D D R E S S E S (Fill Out Below If Appliable) I, attorney for D.S.S. 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 an appointment. (Signature) pcpfc - c.g.f. American LegalNet, Inc. www.USCourtForms.com