AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDINGS Pursuant to Trial Court Rule IV Boston Municipal Court Section 1 Name of Case TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER District Court Division Juvenile Court Division x Probate & Family Court Division Superior Court Division I, NAME OF PARTY (PRINT) , hereby declare, to the best of my knowledge, information and belief that all the information on this form is true and complete: The name(s) of the child(ren) whose care or custody is at issue in this case are: Section 2 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 that child in completing the remaining sections. The party filing this affidavit may request certain addresses 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 the party who completed this affidavit believed this provision applied to him/her, then the box at the right has been checked and sections 4 and 5 have not be completed. The address(es) of the above-named child(ren) whose care or custodyis at issue in this case are: Address(es) Address(es) During the Last 2 Years, If Different Section 3 Section 4 CHILD A. CHILD B. CHILD C. Section 5 Section 6 I My address is: have have not participated in and I know do not know of other care or custody proceedings involving the above-named child(ren) in Massachusetts or in any other state or country. Certified copies of any pleadings or determination in a care or custody proceeding outside of Massachusetts listed in sections 7 and 8 must be filed with this affidavit unless already filed with this court or an extension for filing these documents has been granted by this court. The following is a list of ALL pending or concluded proceedings I have participated in or know of involving the care or custody of the above-named child(ren): Status of Case (Custody awarded to) Letter of Child Court Docket No. (Date of award) CHILD CHILD CHILD [W] itness [P] arty [O] ther [N] one [ [ [ ] ] ] Section 7 The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or those claiming a legal right to these child(ren) during the last two years (not including myself) are: Section 8 Letter of Child CHILD CHILD CHILD Section 9 Name of Party/Claimant Current (or last known) Address of Party/Claimant If the box at the right is checked, this affidavit discloses the adoption of one or more of the abovenamed 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 adjudged incompetent in which case the attorney of record must sign. A revised affidavit must be filed with the court if new information is discovered subsequent to this filing. Signed this day of 20 under the penalties of perjury. SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE ADDRESS OF ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE PRINTED NAME OF PERSON SIGNING THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION OCAJ-1 TCR IV - AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDINGS C.G.F. American LegalNet, Inc. www.FormsWorkFlow.com