STATE OF MAINE DISTRICT COURT Location _____________________ Docket No. ___________________ Plaintiff v. AFFIDAVIT FOR CONFIDENTIAL ADDRESS 19-A M.R.S. § 1653(6)(D) Defendant For the protection of the address confidential. The plaintiff's plaintiff defendant this request is made to keep his / her defendant's address is: The undersigned plaintiff defendant states under oath that the health, safety or liberty of myself and/or my child(ren) would be jeopardized by disclosure of this information for the following reasons: Date: Signature Personally appeared the above named and signed and made oath to the truth of the statements in the above affidavit, before me, Date: FM-057, Rev. 04/14 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com Clerk / Notary Public / Attorney at Law