FC-59 (revised July 2018) Page 1 of 2 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT STATEMENT LISTING CHILDREN Plaintiff Civil Action File Number Defendant Murray Judicial Complex Newport County 45 Washington Square Newport, Rhode Island 02840 - 2913 (401) 841 - 8340 Noel Judicial Complex Kent County 222 Quaker Lane Warwick, Rhode Island 02886 - 0107 (401) 822 - 6725 McGrath Judicial Complex Washington County 4800 Tower Hill Road Wakefield, Rhode Island 02879 - 2239 (401) 782 - 4111 Garrahy Judicial Complex Providence/Bristol County One Dorrance Plaza Providence, Rhode Island 02903 - 2719 (401) 458 - 3200 List below names, addresses , and dates of birth for all children under eighteen ( 18 ) years of age. DATE OF NAME ADDRESS BIRTH GENDER American LegalNet, Inc. www.FormsWorkFlow.com FC-59 (revised July 2018) Page 2 of 2 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT Do any of these children receive Public Assistance ? Yes No Has anyone applied for Public Assistance for any of these children ? Yes No I s there presently in this court any outstanding Order of Support which resulted from an action brought by the Department of Human Services, Office of Child Support Services (OCSS ) under the Reciprocal Enforcement of Support Act? Yes No Name of the P laintiff or the D efendant Signature State of County of On this day of , 20, before me, the undersigned notary public, personally appeared personally known to me or proved to me through satisfactory evidence of identification, which was , to be the person who signed above in my presence, and who swore or affirmed to me that the contents of the document are truthful to the best of his or her knowledge. Notary Public: My commission expires: Notary identification number: American LegalNet, Inc. www.FormsWorkFlow.com