Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No: Case Name: Public Assistance Affidavit 1. I, petitioner/plaintiff, hereby declare that I have made inquiry and, to the best of my knowledge, information and belief all of the information on this form is true, accurate and complete. 2. The name(s) and address(es) of the child(ren) who is/are the subject of this complaint or petition: Name (s) Address 3a. I am receiving public assistance. Yes No b. I have received public assistance in the past. Yes No If the response is yes to either 3a or 3b, please specify the type of public assistance received: Department of Transitional Assistance (Public Welfare) Department of Social Services Department of Medical Assistance (Medicaid) Other (Please Specify) 4a. The child(ren) listed is/are receiving public assistance. Yes b. The child(ren) listed has/have received public assistance in the past. No Yes No If the response is yes to either 4a or 4b, please specify the type of public assistance received: Department of Transitional Assistance (Public Welfare) Department of Social Services Department of Medical Assistance (Medicaid) Other (Please Specify) This affidavit must be personnally signed by the petitioner/plaintiff listed in Section 1. If the petitioner/plaintiff is under the age of 18 years and is represented by an attorney, the attorney must also sign this affidavit. A revised affidavit must be filed with the Court if new information is discovered subsequent to this filing. Signed this day of 20 Signature: Printed Name: Attorney: Printed Name: c.g.f. American LegalNet, Inc. www.FormsWorkFlow.com