JV-112 (Rev. 07/31/2013) AFFIDAVIT IN SUPPORT OF PETITION FORINSPECTION OF RECORDS OF ADOPTIONG.L. c. 210, 247 5C DOCKET NUMBER Trial Court of MassachusettsJuvenile Court Department NAME OF ADOPTED PERSON DIVISION ANSWER THE FOLLOWING QUESTIONS 1. The current name of the individual is: 2. My relationship to the individual adopted is: 3. I am applying to examine the adoption records for the following reasons: ANSWER NUMBERS 4 THROUGH 11, IF KNOWN BY YOU 4. The birth name of the individual is: 5. The birth date of the individual is: 6. The birth mother's name is/was: 7. The birth father's name is/was: 8. The adoptive mother's name is/was: 9. The adoptive father's name is/was:10. The date and place of the adoption was:11. The circumstances surrounding the adoption were: Signed under the pains and penalties of perjury this day of , 20 .Petitioner's Signature:Petitioner's Name (printed):Petitioner's Address: American LegalNet, Inc. www.FormsWorkFlow.com