Public Assistance Affidavit
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Public Assistance Affidavit Form. This is a Massachusetts form and can be use in Probate And Family Court Statewide.
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Tags: Public Assistance Affidavit, Massachusetts Statewide, Probate And Family Court
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(s) of the child(ren) who is/are the subject of this complaint or petition:
Address
Name(s)
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
Division of Medical Assistance (Medicaid)
Other (Please specify)
4a. The child(ren) listed is/are receiving public assistance.
Yes
No
b. The child(ren) listed has/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
Division 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
200
Signature:
Printed Name:
Attorney:
under the penalty of perjury.
Printed Name:
bcpfc - c.g.f.
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